HF Form

MM slash DD slash YYYY
Do you have any of the following symptoms?
Are you breathless at rest?(Required)
Dry Cough (a possible side effect of Ramipril, Captopril, Lisinopril or Enalapril)(Required)
Do you always remember to take your medication?(Required)
Are you buying your own Aspirin?(Required)
Do you have shortness of breath?(Required)
Do you have Leg Swelling?(Required)
Do you ever wake up suddenly at night feeling short of breath/unable to breath, and have to sit up?(Required)
Smoking Status(Required)
We need to know your New York Heart Association (NYHA) Classification Score. Please select one of the below:(Required)
  • Class I – No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc.
  • Class II – Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
  • Class III – Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances. Comfortable only at rest.
  • Class IV – Severe limitations. Experiences symptoms even while at rest.

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