Heart Failure: Symptom Record

Topic Overview

Use this form to describe the severity of your heart failure symptoms and whether they get worse. Also, record any new symptoms that develop. Take this form with you when you visit your doctor.

Symptoms

Describe severity of symptoms and when they started

Shortness of breath



 

Swelling in your legs or ankles



 

Sudden weight gain



 

Tiredness or weakness




 

Dizziness or feeling like you might faint



 

Not sleeping well



 

Other symptoms



 

Credits

Current as ofApril 9, 2019

Author: Healthwise Staff
Medical Review: Rakesh K. Pai MD, FACC - Cardiology, Electrophysiology
Martin J. Gabica MD - Family Medicine
Adam Husney MD - Family Medicine
George Philippides MD - Cardiology