Heart Failure Interview Intake Tool

Introduction Response
How do you feel today?
Is there anything that you would like to make sure that we discuss today?
Ask open ended question about the patient’s cardiovascular history, if unknown. (e.g., cardiac catheterization, stress testing)
Have you been hospitalized? Seen in the emergency room? Or seen another provider since your last visit in this clinic?
If the answer is yes, when was the last time you were seen by another provider/hospitalized? What was the reason for that visit/hospitalization?
Were any doses of your medications changed during that admission/last visit? Were any medications added or stopped? Obtain the details for any positive responses.
Symptom Assessment:  
Assessing shortness of breath
Do you ever get short of breath?
When does the shortness of breath occur? If you do not get a good description, ask if it occurs at rest or with exertion. Have the patient compare their shortness of breath to a previous time point (better/worse/the same)
Do you exercise or take a walk on a regular basis? Tell me about your regimen. For patients who do not ask them if they go to the grocery store and if there are limitations with this.
How far are you able to walk before you have to stop? What causes you to stop? Have the patient compare this to a previous time point (better/worse/the same)
Do you have stairs at home or encounter any stairs throughout the day?
If so do you ever get short of breath walking up the steps? After how many? Have the patient compare this to a previous time point (better/worse/the same)
Do you have to stop climbing due to reasons other than shortness of breath?
Have you noted any shortness of breath or tiredness when completing daily activity such as showering? Cleaning? Getting dressed? Ask about each of these separately.
If yes, please you describe what causes you to become short of breath.
How does this compare to last month/prior to your hospitalization/to last visit etc?
Do you get short of breath when you bend down to tie or put on your shoes?
Orthopnea/Paroxysmal nocturnal dyspnea
Do you sleep in a bed or in a chair?
How many pillows are behind your head when you sleep? How does this compare to last month/prior to your hospitalization/to last visit?
Would you become short of breath if I asked you to sleep flat in bed?
Do you wake up short of breath at night? If yes, how many times a night? Per week?  How does this compare to last month, etc.?
What do you do when you wake up short of breath? Sit upright? Lean over?
Do any other symptoms accompany this shortness of breath?
Have you noticed any swelling in your legs?
If so, how long has it been there and how far up the leg does the swelling go? Men with thigh edema should be asked about scrotal edema.
Have you noticed any swelling/distention in your abdomen?
Do your pants feel loser, tighter or about the same compared to a point in time? Have you had to change pant size or loosen your belt?  
Have you noticed any feelings of fullness when eating?
How often do you weigh yourself at home?
If the patient weighs him/herself:
In the last two weeks what has been your typical reading?
What is the highest number you have seen in the last two weeks?
What is the lowest number you have seen in the last two weeks?
Other symptoms (for each of these be sure to expand about positive responses)
Do you experience any dizziness/lightheadedness?
Have you experienced any chest pain?
For those with sublingual nitroglycerin – have you had to take any since your last visit?
Do you have any palpitations?
Diet and social history
Tell me about your diet. What do you normally eat on a daily basis?
How has your appetite been?
Do you try to limit sodium? If so, how? Do you monitor your total daily intake and limit to a certain amount (i.e., 1500 mg or 2000 mg)?
How often do you add table salt to your food?
If not using salt do you ever utilize a salt substitute? (Salt substitutes that look like table salt should typically be avoided as they contain potassium)
How often do you eat out?
Do you eat canned food? How often?
Do you ever eat frozen entrees? How often?
How often do you use tobacco products?  Employ the 5 A’s if the patient uses tobacco products.
How much alcohol do you consume per week? Per month?  
Do you use illicit drug (e.g., cocaine, marijuana)?  How often?  
Medication Adherence Go through each mediation (Name, dose, route, strength, frequency)  
Then circle below which most reflects the patient’s adherence

·       Takes all medications as prescribed

·       Misses ______ doses per week

·       Misses ______ doses per month

Medications missed: (list)



Are you taking any over the counter medications? Provide one or two examples to the patient.
Do you ever take ibuprofen, naproxen – anything for pain? (These should be avoided in patients with heart failure and patients should be advised to find alternative treatment options such as acetaminophen)
Have you had any issues with your medications? Have you noticed any changes since the last dose adjustment?
Are you in need of any refills on your medications today?