7 Heart Failure Survey

FORM CODE:HFS
VERSION A: 12/12/2007

JHS Heart Failure Survey

OMB# 0925-0491

EXPIRATION DATE XX/XXXX

ID NUMBER: _________________________________________

CONTACT YEAR NUMBER: ______________________________________ SEQUENCE NUMBER _________________

PATIENT NAME: Ms./Mr. _________________________________________________ PATIENT DATE OF BIRTH ____________ Last Name First Name MM/DD/YYYY

1

(If response is NO, skip to question 3)

. Has this patient ever had heart failure or cardiomyopathy of any type?
□ Yes □ Unsure □ No

2. If this patient has or ever had heart failure or cardiomyopathy:

   1. Is this patient’s condition characterized as predominantly:
      □ Systolic dysfunction □ Diastolic dysfunction □ Mixed □ Not determined
      
      

   2. Estimate LVEF (worst): __________%
      (b.1) If LVEF is not specifically available, estimate LV function:
      □ Normal □ Decreased mildly □ Decreased moderately □ Decreased severely
      
      

   3. Estimate date of onset or diagnosis: _____/___________ (Month/year)
      
      

2. Has this patient ever had (check all that apply):
   □ Atrial fibrillation on an ECG? □ Pulmonary rales on a physical examination
   □ Angina pectoris? □ Rhonchi on a physical examination?
   □ Previous MI? □ Other coronary heart disease?
   □ None of the above
   
   

3. Was she/he prescribed treatment specifically for heart failure during the past year?
   □ Yes □ No □ Not known
   
   

4. W

   □ ACE inhibitors □ Anticoagulants □ Diuretics

   □ Alpha blockers □ Aspirin / Antiplatelets □ Hydralazine

   □ Aldosterone blocker □ Beta blockers □ Lipid-lowering agents
   □ Amiodarone / Antiarrhythmics □ Calcium channel blockers □ Nitrates

   □ Angiotensin II receptor blocker □ Digitalis □ Other antihypertensives

   □ Hydralazine/Nitrate combination (BiDil)

   
   

   as this patient prescribed any of the following during the past year? (check all that apply)
   
   
   
   
   
   
   

5. H as the patient undergone any procedures related to HF? (Check all that apply)
   □ ICD implantation □ Re-synchronization therapy □ Other
   
   
   Form Completed By: Date:
   
   
   (Signature or stamp) (MM/DD/YY)

HFS 11/02/2007 Page 1