HEART HEALTH HISTORY

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

  1. I have experienced these symptoms: Circle all that apply.
    • A sensation of fluttering my chest
    • Chest pain
    • Shortness of breath
    • Light-headedness
    • None of the above
  2. I feel symptoms:
    • Continuously
    • Occasionally
  3. Does anything improve or worsen your symptoms?
  4. I first started experiencing symptoms _____(Month) ______(Year).
  5. I have lost or gained weight in the past 12 months.
    • Yes
      No
      Amount of weight lost or gained:
  6. I exercise.
    • Yes
      No
  7. I exercise ___ times per week. The exercise I engage in is______________.
  8. During physical exercise I feel:
  9. I feel tired easily when performing routine activities.
    • Yes
      No
  10. I have a history of heart disease in my family.
    • Yes
      No
      If yes, please explain:
  11. I have these health conditions:
  12. I take the following medications (including over-the-counter medications):