KCCQ-12 Scoring Tool

1a. How much are you limited by heart failure (shortness of breath or fatigue) in Showering/Bathing?

Extremely Limited Quite a bit Limited Moderately Limited Slightly Limited Not at all Limited

1b. ...in Walking 1 block on level ground?

Extremely Limited Quite a bit Limited Moderately Limited Slightly Limited Not at all Limited

1c. ...in Hurrying or Jogging (as if to catch a bus)?

Extremely Limited Quite a bit Limited Moderately Limited Slightly Limited Not at all Limited

2. Over the past 2 weeks, how many times did you have swelling in your feet, ankles, or legs when you woke up?

Every Morning 3+ times a week 1-2 times a week Less than once a week Never

3. Over the past 2 weeks, how often has fatigue limited your ability to do what you wanted?

All of the time Several times per day At least once per day 3+ times per week 1-2 times per week Less than once a week Never

4. Over the past 2 weeks, how often has shortness of breath limited your ability to do what you wanted?

All of the time Several times per day At least once per day 3+ times per week 1-2 times per week Less than once a week Never

5. Over the past 2 weeks, how often have you been forced to sleep sitting up or with at least 3 pillows due to shortness of breath?

Every Night 3+ times per week 1-2 times per week Less than once a week Never

6. Over the past 2 weeks, how much has heart failure limited your enjoyment of life?

Extremely limited Limited quite a bit Moderately limited Slightly limited Not limited at all

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?

Not at all satisfied Mostly dissatisfied Somewhat satisfied Mostly satisfied Completely satisfied

8a. Over the past 2 weeks, how much has your heart failure limited your participation in Hobbies/recreational activities?

Severely limited Limited quite a bit Moderately limited Slightly limited Did not limit at all

8b. ...in Working or doing household chores?

Severely limited Limited quite a bit Moderately limited Slightly limited Did not limit at all

8c. ...in Visiting family or friends out of your home?

Severely limited Limited quite a bit Moderately limited Slightly limited Did not limit at all

HeartForms