Form CMS-10443 KCCQ-10
Transcatheter Valve Therapy Registry and KCCQ-10
short kccq 2012-01-31.DOCX
KCCQ-10
OMB: 0938-1202
KCCQ-10
The following questions refer to your heart failure and how it may affect your life. Please read and complete the following questions. There are no right or wrong answers. Please mark the answer that best applies to you.
Heart failure affects different people in different ways. Some feel shortness of breath while others feel fatigue. Please indicate how much you are limited by heart failure (shortness of breath or fatigue) in your ability to do the following activities over the past 2 weeks.
-
Activity
Extremely
Limited
Quite a bit
limited
Moderately
Limited
Slightly
limited
Not at all
limited
Limited for
other reasons
or did not do
the activity
Walking 1 block on
level ground
O
O
O
O
O
O
Climbing a flight of stairs without stopping
O
O
O
O
O
O
Over the past 2 weeks, on average, how many times has fatigue limited your ability to do what you wanted?
-
All of
the time
Several times per day
At least
once a day
3 or more times per week but not every day
1-2 times
per week
Less than
once a week
Never over the
O
O
O
O
O
O
O
Over the past 2 weeks, how much has your fatigue bothered you?
It has been…
-
Extremely bothersome
Quite a bit bothersome
Moderately bothersome
Slightly bothersome
Not at all bothersome
I’ve had
no fatigue
O
O
O
O
O
O
Over the past 2 weeks, on average, how many times has shortness of breath limited your ability to do what you wanted?
-
All of
the time
Several times per day
At least
once a day
3 or more times per week but not every day
1-2 times
per week
Less than
once a week
Never over the
past 2 weeks
O
O
O
O
O
O
O
Over the past 2 weeks, how much has your shortness of breath bothered you?
It has been…
-
Extremely bothersome
Quite a bit bothersome
Moderately bothersome
Slightly bothersome
Not at all bothersome
I’ve had no shortness of breath
O
O
O
O
O
O
Over the past 2 weeks, how much has your heart failure limited your enjoyment of life?
-
It has extremely limited my enjoyment of life
It has limited my enjoyment of life quite a bit
It has moderately limited my enjoyment of life
It has slightly
limited my enjoyment of life
It has not limited
my enjoyment
of life at all
O
O
O
O
O
If you had to spend the rest of your life with your heart failure the way it is right now, how would you feel about this?
-
Not at all
satisfied
Mostly
dissatisfied
Somewhat
satisfied
Mostly
satisfied
Completely
satisfied
O
O
O
O
O
How much does your heart failure affect your lifestyle? Please indicate how your heart failure may have limited your participation in the following activities over the past 2 weeks.
-
Activity
Severely
Limited
Limited
quite a bit
Moderately limited
Slightly limited
Did not
limit at all
Does not apply or did not do for other reasons
Hobbies, recreational activities
O
O
O
O
O
O
Visiting family or friends out of your home
O
O
O
O
O
O
Rev. 2012-01-31
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | SAQ-6 |
| Author | Phil Jones |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |
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