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Cardiac Patient Forms
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Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
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Dartmouth Quality of Life Index
Feelings
During the past 4 weeks how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, or downhearted and blue?
*
Not at all
Slightly
Moderately
Quite a bit
Extremely
Physical Fitness
During the past 4 weeks what was the hardest physical activity you could do for at least 2 minutes?
*
Very heavy: run fast, carry heavy loads uphill
Heavy: jog, climb stairs or hill
Moderate: walk medium, carry heavy loads
Light: walk medium, carry light loads
Very Light: walk slow, wash dishes
Social Support
During the past 4 weeks was someone available to help you if you needed and wanted help? For example, if you: -Felt very nervous, lonely, or blue -Got sick and had to stay in bed -Needed someone to talk to-Needed help with daily chores -Needed help just taking care of yourself
*
Yes, as much as I wanted
Yes, quite a bit
Yes, some
Yes, a little
No, not at all
Daily Activities
During the past 4 weeks how much difficulty have you had doing your usual activities or tasks, both inside and outside the house because of your physical and emotional health?
*
No difficulty at all
A little bit of difficulty
Some difficulty
Much difficulty
Could not do
Social Activities
During the past 4 weeks has your physical and emotional health limited your social activities with family, friends, neighbors, or groups?
*
Not at all
Slightly
Moderately
Quite a bit
Extremely
Pain
During the past 4 weeks how much bodily pain have you generally had?
*
No pain
Very mild pain
Mild pain
Moderate pain
Severe pain
Overall Health
During the past 4 weeks how would you rate your health in general?
*
Excellent
Very good
Good
Fair
Poor
Quality of Life
How have things been going for you during the past 4 weeks?
*
Very well-could hardly be better
Pretty good
Good & bad parts about equal
Pretty bad
Very bad-could hardly be worse
Change in Health
How would you rate your overall health now compared to 4 weeks ago?
*
Much better
A little better
About the same
A little worse
Much worse
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Last Name
Patient Health Questionnaire
Over the last 2 weeks, how often have you been bothered by any of the following problems?
*
Rows
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Little interest or pleasure in doing things.
Feeling down, depressed, or hopeless.
Trouble falling/staying asleep, sleeping too much.
Feeling tired or having little energy.
Poor appetite or overeating.
Feeling bad about yourself, or that you are a failure, or have let yourself or your family down.
Trouble concentrating on things, such as reading the newspaper or watching TV.
Moving or speaking so slowly that other people could have noticed. Or the opposite; being so fidgety or restless that you have been moving around more than usual.
Thoughts that you would be better off dead or of hurting yourself in some way.
Total Score
If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
*
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
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First Name
Last Name
STOPBANG
Screening Tool for Obstructive Sleep Apnea
Please answer the following questions below:
SNORING: Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
*
Yes
No
TIREDNESS OR FATIGUE: Do you often feel tired, fatigued or sleepy during the daytime – even after a good night’s sleep?
*
Yes
No
OBSERVED APNEA: Has anyone ever observed you stop breathing during your sleep?
*
Yes
No
PRESSURE: Are you being treated for high blood pressure?
*
Yes
No
BODY MASS INDEX (BMI) over 35:
*
Yes
No
Use this to calculate your BMI
*
AGE: Are you older than 50 years?
*
Yes
No
NECK SIZE: Does your neck measure more than 17 inches around (male) or more than 16 inches around (female)?
*
Yes
No
If yes, what is your neck size in inches?
GENDER: Are you male?
*
Yes
No
SCORE
If you have answered Yes to 3 or more of these questions, there is a likelihood of Obstructive Sleep Apnea.
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