Form CMS-10443 KCCQ Form

Kansas City Cardiomyopathy Questionnaire (KCCQ-12)
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.
Limited for
other reasons
Extremely
Quite a bit
Moderately
Slightly
Not at all
or did not do
Activity
Limited
Limited
Limited
Limited
Limited
the activity
a. Showering/bathing

O

O

O

O

O

O

b. Walking 1 block on
level ground

O

O

O

O

O

O

c. Hurrying or jogging
(as if to catch a bus)

O

O

O

O

O

O

1

2

3

4

5

6

2. Over the past 2 weeks, how many times did you have swelling in your feet, ankles or legs when you woke up in the
morning?
3 or more times
per week but
Less than
Never over the
Every morning
not every day
1-2 times per week
once a week
past 2 weeks

O

O

O

O

O

1

2

3

4

5

3. 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

1

2

3

4

5

6

7

4. Over the past 2 weeks, on average, how many times has shortness of breath limited your ability to do what you
wanted?
3 or more times
All of
Several times
At least
per week but
1-2 times
Less than
Never over the
the time
per day
once a day
not every day
per week
once a week
past 2 weeks

O

O

O

O

O

O

O

1

2

3

4

5

6

7

5. Over the past 2 weeks, on average, how many times have you been forced to sleep sitting up in a chair or with at
least 3 pillows to prop you up because of shortness of breath?

Every night

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

1

2

3

4

5

Rev. 2012-04-11

KCCQ-12
Page 2 of 2
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

1

2

3

4

5

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

1

2

3

4

5

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

a. Hobbies, recreational
activities

O

O

O

O

O

O

b. Working or doing
household chores

O

O

O

O

O

O

c. Visiting family or
friends out of your
home

O

O

O

O

O

O

1

2

3

4

5

6

Activity

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Rev. 2012-04-16