Congestive Heart Failure Assessment

This short survey will only take a few minutes to complete and will help us monitor how you are doing. If you are a caregiver, please answer the questions as they relate to the Fidelis Care member identified below.

Name

First Last

How would you rate your level of overall health and well-being?*

Do you have the ability to weigh yourself at home?*

Yes
No

What is your current weight?*

Please enter in pounds

In the last week, have you experienced swelling?*

No
Not Sure
Yes

Please rate your swelling*

Mild
Moderate
Severe

Have you experienced shortness of breath?*

No
Not Sure
Yes

Please rate your shortness of breath*

Mild
Moderate
Severe

Have you stopped using any prescriptions for your heart failure?*

Yes
No

Please let us know why*

I can't afford the prescription
I don't like the side effects
I forget
I ran out
Other

What other reason did you stop taking your prescriptions?*

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Health Rating

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Call CC

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Call Provider

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region

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mobile

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county

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status

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LastWeight

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WeightChange

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Escalate Weight

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