Get UAB KCCQ-12 2012-2024

Protocol 4. 0 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 other reasons Extremely Quite a bit Moderately Slightly Not at all or did not do Activity limited the activity a* Showering/bathing O b. Walking 1 block on level ground c* Hurrying or jogging as if to catch a bus 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 All of the time Several times per day At least once a day 1-2 times wanted least 3 pillows to prop you up because of shortness of breath Every night Rev* 2012-04-19 Page 2 of 2 It has extremely limited my enjoyment of life It has limited my enjoyment of life It has moderately It has slightly my enjoyment of life at all 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 satisfied Mostly Somewhat Completely 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 Did not limit at all Does not apply a* Hobbies recreational activities b. Working or doing household chores c* Visiting family or friends out of your home. 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. 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. 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 other reasons Extremely Quite a bit Moderately Slightly Not at all or did not do Activity limited the activity a* Showering/bathing O b. Limited for other reasons Extremely Quite a bit Moderately Slightly Not at all or did not do Activity limited the activity a* Showering/bathing O b. Walking 1 block on level ground c* Hurrying or jogging as if to catch a bus 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 All of the time Several times per day At least once a day 1-2 times wanted least 3 pillows to prop you up because of shortness of breath Every night Rev* 2012-04-19 Page 2 of 2 It has extremely limited my enjoyment of life It has limited my enjoyment of life It has moderately It has slightly my enjoyment of life at all 7. .