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? | |
| Edema | |
| 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? | |
| Weight | |
| 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 |
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| Medications missed: (list)
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| 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? |