• 1.Do you feel palpitation, chest tightness and shortness of breath?
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  • A、No, I never have the symptoms.0
  • B、Yes, the symptoms appear after light exercise.2
  • C、Yes, the symptoms appear when I have a rest and occasionally I wake up due to shortness of breath.4
  • D、Yes, I cannot breathe when lying flat and I need to sit up to get into sleep.6
  • 2.Do you often cough and wheeze?
  • 这道题还未作答,不能提交答卷
  • A、No, I do not cough very often.0
  • B、Yes, I cough occasionally with white sputum3
  • C、Yes, I cough very often with white sputum and occasionally I cough with bloody sputum.6
  • 3.Please describe your fatigue condition after labor or physical activity!
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  • A、I can handle normal activities in my daily life.0
  • B、I feel tired during my daily activity and it is getting worse.3
  • C、I feel tired even at rest.6
  • 4.Please specify the severity of edema in your lower limbs.
  • 这道题还未作答,不能提交答卷
  • A、Feet and legs look normal, no signs of any edema.0
  • B、Edema appeared in either foot, leg or ankle, and it is getting worse.3
  • C、Edema and discomfort appeared throughout my lower limbs, and it is getting worse.6
  • 5.Is there any significantly change in your weight for any unknown reason recently?
  • 这道题还未作答,不能提交答卷
  • A、My body weight is always stable.0
  • B、I have gained 1-1.5 kg of body weight in 24 hours or 2.5 kg in 1 week.4
  • 6.How is your overall condition and cognitive ability?
  • 这道题还未作答,不能提交答卷
  • A、I often feel dizzy.2
  • B、My memory is declining.2
  • C、My heart rate is increasing.2
  •  D、None of above.0
  • 7.Please describe your sleep condition.
  • 这道题还未作答,不能提交答卷
  •   A、Normal.0
  •   B、It is hard to fall asleep.3
  •   C、It is harder to fall asleep and I cannot lie flat.6
  • 8.Has your appetite been changed recently?
  • 这道题还未作答,不能提交答卷
  •   A、Normal0
  •   B、I do not have a good appetite recently2
  •   C、I feel nausea occasionally.4
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The above questionnaire is only a reference for your personal health evaluation, it cannot be the evidence of medical diagnosis.

Reference

[1]. Yancy, C.W., et al., 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation, 2017. 136(6): p. e137-e161.

[2]. Yancy, C.W., et al., 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation, 2013. 128(16): p. e240-327.

[3] Chinese Society of Cardiology of Chinese Medical Association, Chinese guidelines for the diagnosis and treatment of heart failure 2014, Zhonghua Xin Xue Guan Bing Za Zhi, 2014, 42(2): 98-122.

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