Congestive Heart Failure Assessment

This short survey will only take a few minutes to complete and will help us monitor how you are doing.

How would you rate your level of overall health and well-being?*

1 = My health and well-being are poor; 10 = My health and well-being are great.

What is your weight today?*

Please enter in pounds

What is your weight today?

Please enter in pounds

In the last two weeks, have you experienced swelling?*

Please rate your swelling*

In the last two weeks, have you experienced shortness of breath?*

Please rate your shortness of breath*

Have you been taking your heart condition medications as prescribed by your doctor?*

Please let us know why?*

"Other" is selected, please describe:*