Heart Failure: Symptom Record

Topic Overview

Use this form to describe the severity of your heart failure symptoms and whether they get worse. Also, record any new symptoms that develop. Take this form with you when you visit your doctor.

Symptoms

Describe severity of symptoms and when they started

Shortness of breath



 

Swelling in your legs or ankles



 

Cough



 

Energy level




 

Weight



 

Urination at night



 

Stomach trouble/bloating/poor appetite



 

Credits

ByHealthwise Staff
Primary Medical Reviewer Rakesh K. Pai, MD - Cardiology, Electrophysiology
Martin J. Gabica, MD - Family Medicine
Adam Husney, MD - Family Medicine
George J. Philippides, MD, FACC - Cardiology

Current as ofDecember 6, 2017

Is it an emergency?

If you or someone in your care has chest pains, difficulty breathing, or severe bleeding, it could be a life-threatening emergency. Call 9-1-1 or the local emergency number immediately.
If you are concerned about a possible poisoning or exposure to a toxic substance, call Poison Control now at 1-800-567-8911.

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