1. Heart Rhythm
Have you noticed your heartbeat feel unusual?
☐ No ☐ Yes ☐ Not sure
If yes or not sure, what does it feel like?
☐ Fast ☐ Slow ☐ Skipping ☐ Fluttering ☐ Not sure
Does it start and stop suddenly?
☐ Yes ☐ No ☐ Not sure
2. Chest Discomfort
Do you experience chest pain, pressure, or tightness?
☐ No ☐ Yes
If yes:
Does it occur at rest or during activity/stress?
☐ Rest ☐ Activity/Stress ☐ Both
How long does it usually last?
☐ Seconds ☐ Minutes ☐ Longer than 10 minutes
3. Activity & Fatigue
Do you get tired more quickly than before?
☐ No ☐ Yes
Has your ability to do everyday activities (walking, climbing stairs, carrying groceries) changed in the past 3–6 months?
☐ No change ☐ Slightly worse ☐ Much worse
4. Breathing
Do you experience shortness of breath?
☐ No ☐ Yes
If yes:
Is it worse when lying down?
☐ No ☐ Yes
Do you need more pillows than before to sleep comfortably?
☐ No ☐ Yes
Do you wake up at night feeling short of breath?
☐ No ☐ Yes
5. Dizziness or Fainting
Do you experience dizziness or near-fainting?
☐ No ☐ Yes
Have you ever lost consciousness?
☐ No ☐ Yes
If yes:
How many times?
☐ Once ☐ More than once
When was the most recent episode?
☐ Within last 3 months ☐ More than 3 months ago
Did it occur during activity or emotional stress?
☐ No ☐ Yes ☐ Not sure
6. Swelling
Do you have swelling of the lower legs or ankles?
☐ No ☐ Yes
If yes:
Does the swelling improve overnight or worsen during the day?
☐ Improves overnight ☐ Worsens during day ☐ Not sure
7. Cough
Have you had a cough that lasts more than a few weeks or keeps coming back?
☐ No
☐ Yes
☐ Not sure
If yes or not sure, is the cough usually:
☐ Dry
☐ Wet (with mucus)
☐ Not sure
Are you taking medication for high blood pressure?
☐ No
☐ Yes
☐ Not sure
Does the cough get worse at night or when lying down?
☐ No ☐ Yes ☐ Not sure
8. Family History
Do you have a family history of heart disease in a close relative (parent or sibling) before age 60?
☐ No ☐ Yes ☐ Not sure
If yes (optional):
Type (if known):
☐ Heart attack
☐ Heart failure
☐ Arrhythmia
☐ Valve disease
☐ Sudden cardiac death
☐ Not sure
9. Anything else concerning you that you wish to discuss?
☐ No ☐ Yes
If yes, details: