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



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