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pdfKCCQ-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.
1. 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.
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
Activity
2. 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
past 2 weeks
O
O
O
O
O
O
O
3. 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
4. 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
5. 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
Rev. 2012-01-31
6. 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
7. 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
8. 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.
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
Activity
Rev. 2012-01-31
| File Type | application/pdf |
| File Title | SAQ-6 |
| Author | Phil Jones |
| File Modified | 2014-07-30 |
| File Created | 2012-08-29 |