HEART HEALTH HISTORY

Print this list of questions, complete the answers and take them with you to discuss with your healthcare team.

  1. My palpitations started suddenly.
    • Yes
      No
  2. My palpitations feel like skipped beats.
    • Yes
      No
  3. My palpitations feel like stopped beats.
    • Yes
      No
  4. I feel my heart racing with my heart palpitations.
    • Yes
      No
  5. I feel my heart pounding with my heart palpitations.
    • Yes
      No
  6. I feel my heart fluttering with my heart palpitations.
    • Yes
      No
  7. There is a regular pattern to my heart palpitations.
    • Yes
      No
  8. There is an irregular pattern to my heart palpitations.
    • Yes
      No
  9. I first started experiencing symptoms _____ (Month) _____ (Year).
  10. I feel the palpitations when I __________________.
  11. The palpitations seem to stop when I_____________________.
  12. I am having additional symptoms (for example, dizziness, shortness of breath, chest pain, fainting): ____________.
  13. I have a history of heart disease in my family.
    • Yes
      No
      If yes, please explain:
  14. I have had emotional strains or recent life changes.
    • Yes
      No
      If yes, please explain:
  15. I take the following medications (including over-the-counter medications):


References

  1. Mayou R. Chest pain, palpitations and panic. J Psychosom Res 1998;44:53-70.
  2. Kroenke K, Arringon ME, Mangelsdroff AD. The prevalence of symptoms in medical outpatients and the adequacy of therapy. Arch Intern Med 1990;150:1685-9.
  3. Knudson MP. The natural history of palpitations in a family practice. J Fam Pract 1987;24:357-60.