HEART HEALTH HISTORY
Print this list of questions, complete the answers and take them with you to discuss with your healthcare team.
- I have experienced these symptoms: Circle all that apply.
- A sensation of fluttering my chest
- Chest pain
- Shortness of breath
- None of the above
- I feel symptoms:
- Does anything improve or worsen your symptoms?
- I first started experiencing symptoms _____(Month) ______(Year).
- I have lost or gained weight in the past 12 months.
Amount of weight lost or gained:
- I exercise.
- I exercise ___ times per week. The exercise I engage in is______________.
- During physical exercise I feel:
- I feel tired easily when performing routine activities.
- I have a history of heart disease in my family.
If yes, please explain:
- I have these health conditions:
- I take the following medications (including over-the-counter medications):
- American Heart Association.
http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-are-the-Symptoms-of-Atrial-Fibrillation-AFib-or-AF_UCM_423777_Article.jsp. Accessed November 2013.