Heart Disease

Do you feel these symptoms limit activities associated with daily living, such as household chores, shopping, or leisure?

Do you ever get these symptoms while resting, after eating, or just watching television?

Do you ever awaken at night with these symptoms?

Have you decreased your activity in the past 6 months due to these symptoms?

Do you avoid activity because you might get these symptoms?

Do you take nitroglycerin tablets before certain activities to prevent these symptoms?

Are you dissatisfied with your current quality of life because of lack of energy, symptoms, or inability to engage in your normal activities of daily living?

Have you ever had an angioplasty or a stent?

Have you ever had bypass surgery?

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Walk a block or two on level ground?

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Climb a flight of stairs or walk uphill?

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Run a short distance?

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Do light work around the house like dusting or washing the dishes?

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Do moderate work around the house like vacuuming, sweeping floors, carrying in groceries?

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Do heavy work around the house like scrubbing floors, lifting or moving heavy furniture?

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Do yard work like raking leaves, weeding or pushing a power mower?

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Have sexual relations?

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football?

Select “Yes” if you can complete a particular activity without significant fatigue, shortness of breath, chest pain, and/or other unusual symptoms or side effects.

Participate in strenuous activities like swimming, singles, tennis, football, basketball or skiing?

During the past 7 days…

I feel fatigued…

During the past 7 days…

I have trouble STARTING things because I am tired…

In the past 7 days…

How run-down do you feel on average?

In the past 7 days…

How fatigued were you on average?

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Feeling down, depressed, or hopeless

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Trouble falling or staying asleep, or sleeping too much

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Feeling tired or having little energy

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Poor appetite or overeating

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Feeling bad about yourself—or that you are a failure or have let yourself or family down

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Trouble concentrating on things, such as reading the newspaper or watching television

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Moving or speaking slowly that other people have noticed. Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual

Over the LAST 2 WEEKS, how often have you been bothered by any of the following problems?

Thoughts that you would be better off dead, or of hurting yourself in some way

Over the LAST 2 WEEKS, if ANY of the problems previously listed bothered you,

how DIFFICULT have these problems made it for you to do your work, take care of things at home, or get along with other people?

Please think about how you have been feeling this past month as you answer the next set of questions.

Do you get short of breath when hurrying on level ground or walking up a slight hill?

Please think about how you have been feeling this past month as you answer the next set of questions.

Do you get short of breath when walking with other people your own age on level ground?

Please think about how you have been feeling this past month as you answer the next set of questions.

Do you get short of breath when walking at your own pace on level ground?

Please think about how you have been feeling this past month as you answer the next set of questions.

Do you get short of breath when washing or dressing?