CHF Survey Instrument

To:          

CC:         

From:     Drs.

Date:      10/22/2001

1.              I understand I have congestive heart failure or CHF

Having CHF means my heart cannot keep up with my bodily needs, unless I take care of myself.

Some of my symptoms are:

A.)              I get winded / short of breath even climbing one flight of stars or walking one block

B.)              I require two pillows or more to sleep

C.)              My color is not good

D.)              I get swelling in my legs or fingers, only in the morning; anytime (circle which)

E.)              I cannot work, cannot do household chores, cannot exercise  (circle which)

2.              I do not feel good and I know it’s my heart (based upon symptoms I have had before that my doctor told me were from heart failure).

3.              I take my weight weekly, daily, only when I go to the mall or doctor’s office  (circle which)

A.)  I have no scale at home

B.)  My body weight increases 1-2 pounds per week | more than a few pounds per week (circle which)

4.              I restrict my daily salt intake to the point my food doesn’t taste good

5.              I exercise – at least walking a half mile a day or similar amount of exercise

6.              I smoke

A.

B.

C.

D.

E.

F.

Generally speaking, I take my medications

1)     Every day

2)     I miss a few doses a day

3)     I only miss one of my pills, occasionally

8.              My Heart Failure has caused me to be hospitalized ___ times this past 12 months

9.              My CHF has caused me to go the ER _____ times this past 12 months

10.         I think my CHF has not caused me to go to the hospital or ER but when I went for other reasons, it was a factor