Heart Failure Interview Intake Tool
|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.
|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?