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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





 

Credits

Current as of: April 29, 2021

Author: Healthwise Staff

Medical Review: Rakesh K. Pai MD, FACC - Cardiology, Electrophysiology

Martin J. Gabica MD - Family Medicine

Adam Husney MD - Family Medicine

George Philippides MD - Cardiology

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