We need to gather some basic information about your condition and the kind of assistance you desire. Some of the information about your condition will help the program know what to expect and help it learn about your case.
Please indicate the following about your condition:
How long have you had heart failure? no heart failure diagnosis diagnosed with a month within 6 months longer
How severe is your heart failure? can exercise and live normally without therapy can exercise and live normally with therapy my exercise is limited or I have days of severe fatigue regularly I have trouble just managing normal living functions I am confined to bed
Are you presently taking diuretics (water pills) for it? Yes, No
Do you have coronary disease (angina)? Yes, No Do you have high blood pressure? Yes, No Do you have diabetes? Yes, No Do you have lung disease? Yes, No Do you have swelling of the ankles not related to your heart failure? Yes, No
Have you smoked in the last 5 years? Yes, No Do you drink alcohol? Yes, No
Please tell me some initial data about your symptoms:
What is your normal weight when not congested? preferred units: pounds kilograms
What symptoms have you had when suffering from heart failure? (click all you have experienced) shortness of breath with exercise shortness of breath at rest need to prop head up to sleep waking up short of breath fatigue or extraordinary tiredness weight gain swelling of the ankles or legs swelling around the middle lightheadedness or dizziness depression -- feeling like life isn't worthwhile swollen feeling in chest or stomach dry cough palpitations (feeling your heart jumping) loss of appetite difficulty sleeping can't lie on your left side numbness, tingling, or pain in your legs or arms difficulty concentrating Others:
Finally, we need a login name and password: Login name: No spaces in the name, please. Password: Password again: email address: This is where we will send any information about your case and also send your password if you forget it.
When you have filled this out completely, please submit it: