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pdfKansas City Cardiomyopathy Questionnaire (KCCQ-12)
The following questions refer to your heart failure and how it may affect your life. Please read and complete the following
questions. There are no right or wrong answers. Please mark the answer that best applies to you.
1. Heart failure affects different people in different ways. Some feel shortness of breath while others feel fatigue. Please
indicate how much you are limited by heart failure (shortness of breath or fatigue) in your ability to do the following
activities over the past 2 weeks.
Limited for
Extremely
Quite a bit
Moderately
Slightly
Not at all
other reasons
Limited
Limited
Limited
Limited
Limited
or did not do
Activity
the activity
a. Showering/bathing
O
O
O
O
O
O
b. Walking 1 block on
level ground
O
O
O
O
O
O
c. Hurrying or jogging
(as if to catch a bus)
O
O
O
O
O
O
2. Over the past 2 weeks, how many times did you have swelling in your feet, ankles or legs when you woke up in the
morning?
3 or more times
Less than
Never over the
per week but
Every morning
1-2 times per week
once a week
past 2 weeks
not every day
O
O
O
O
O
3. Over the past 2 weeks, on average, how many times has fatigue limited your ability to do what you wanted?
All of
the time
Several times
per day
At least
once a day
3 or more times
per week but
not every day
1-2 times
per week
Less than
once a week
Never over the
past 2 weeks
O
O
O
O
O
O
O
4. Over the past 2 weeks, on average, how many times has shortness of breath limited your ability to do what you
wanted?
3 or more times
All of
Several times
At least
1-2 times
Less than
Never over the
per week but
the time
per day
once a day
per week
once a week
past 2 weeks
not every day
O
O
O
O
O
O
O
5. Over the past 2 weeks, on average, how many times have you been forced to sleep sitting up in a chair or with at
least 3 pillows to prop you up because of shortness of breath?
Every night
3 or more times
per week but
not every day
1-2 times
per week
Less than
once a week
Never over the
past 2 weeks
O
O
O
O
O
Rev. 2012-04-11
KCCQ-12
Page 2 of 2
6. Over the past 2 weeks, how much has your heart failure limited your enjoyment of life?
It has extremely
limited my enjoyment
of life
It has limited my
enjoyment of life
quite a bit
It has moderately
limited my enjoyment
of life
It has slightly
limited my enjoyment
of life
It has not limited
my enjoyment
of life at all
O
O
O
O
O
7. If you had to spend the rest of your life with your heart failure the way it is right now, how would you feel about this?
Not at all
satisfied
Mostly
dissatisfied
Somewhat
satisfied
Mostly
satisfied
Completely
satisfied
O
O
O
O
O
8. How much does your heart failure affect your lifestyle? Please indicate how your heart failure may have limited your
participation in the following activities over the past 2 weeks.
Severely
Limited
Limited
quite a bit
Moderately
limited
Slightly
limited
Did not
limit at all
Does not apply
or did not do for
other reasons
a. Hobbies, recreational
activities
O
O
O
O
O
O
b. Working or doing
household chores
O
O
O
O
O
O
c. Visiting family or
friends out of your
home
O
O
O
O
O
O
Activity
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Rev. 2012-04-16
| File Type | application/pdf |
| File Title | Kansas City Cardiomyopathy Questionnaire for Patients (with numbering) |
| Author | CMS |
| File Modified | 2020-09-01 |
| File Created | 2020-09-01 |