Heart failure review

Are you experiencing chest pain? *

Yes

No

Are you experiencing severe shortness of breath? *

Yes

No

If you are experiencing chest pain or severe shortness of breath or other concerning symptoms, please follow your care plan (if you have one) or ring your GP or 999 immediately.

Section

How much effect is your heart failure having on your daily activities? *

No symptoms with no limitations on physical activity

Mild symptoms with slight limitation of physical activity but comfortable at rest

Moderate symptoms with marked limitation of physical activity but still comfortable at rest

Severe symptoms causing inability to perform physical activity without discomfort, symptoms at rest

Have you had any shortness of breath? *

No breathlessness

Yes – Breathlessness on mild exertion

Yes – Breathlessness on moderate exertion

Yes – Breathlessness on strenuous exertion

Do you feel breathless when you lie flat? *

No – comfortable with one pillow or none

Yes – need more than 1 pillow

Yes – need more than 2 pillows

Yes – need more than 3 pillows

Do you wake up in the night gasping for breath? *

Yes

No

Do you have any leg swelling? *

Yes

No foot, ankle or leg swelling

Please specify:

Swelling of feet

Swelling of ankles

Swelling up legs

How is your mood? *

Fine

Low

How is your memory? *

Fine

Reduced

If any of the problems are new or getting considerably worse, please telephone the surgery for further assessment. In an emergency, you should call 999.

Home Blood Pressure Recordings

Please complete this section if you have a blood pressure monitor at home. Otherwise, please leave this blank and skip to the next section.

In the morning, ensure that you are rested and have taken no exercise in the last 30 minutes. Then sit in a chair comfortably upright with your arm supported on the table beside you, put both feet on the ground. Put the cuff on your upper arm (5cm above your elbow) resting on the table, the cuff should be roughly at the level of your heart. Press the on/start button on the BP monitor and take two readings at least 1 minute apart. Record the readings with your pulse rate and any comments and repeat that evening for a total of 7 days using alternate arms.

Calculate your average blood pressure by ignoring the first day of readings (as this was when you were getting used to the monitor) and take an average of the remaining readings. Add up all the top systolic blood pressures and divide by the number of blood pressures done, then repeat with the bottom diastolic blood pressures.

Average Systolic

mmHg

/

Average Diastolic

mmHg

Pulse rate

bpm

The rhythm of my pulse is:

Regular

Irregular

About You

Height (in Meters):

eg. 1.75

Weight (in Kilograms):

eg. 60.6

BMI:

Alcohol Consumption

One unit of alcohol

Amount of different types of drink representing one unit of alcohol

More than one unit of alcohol

Amount of different types of drink representing more than one unit of alcohol

How often do you have a drink containing alcohol? *

How many units of alcohol do you drink on a typical day when you are drinking? *

Unit calculator

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Score:

Smoking

Smoking status: *

Never smoked

Ex-smoker

Trivial smoker (less than 1 cigarette per day)

Light smoker (1-9 cigarettes per day)

Moderate smoker (10-19 cigarettes per day)

Heavy smoker (20-39 cigarettes per day)

Very heavy smoker (40 or more cigarettes per day)

Do you use an e-cigarette? *

Yes

No

Ex-user

Would you like to give up smoking? *

Yes

No

If you would like help or advice to stop smoking, please visit NHS Quit Smoking.

I have the following questions that I would like to raise with my Nurse or Doctor:

*

I confirm that the information provided is accurate to the best of my knowledge