SCHFI English 

Authored by

Barbara Riegel, PhD, RN, FAAN, FAHA

Professor of Gerontology

Penn Nursing
University of Pennsylvania
418 Curie Boulevard
Philadelphia, PA 19104-4217

email: briegel@nursing.upenn.edu

SELF-CARE OF HEART FAILURE INDEX

All answers are confidential.

Think about how you have been feeling in the last month as you complete this survey.

 

SECTION A:

Listed below are behaviors that people with heart failure use to help themselves. How often or routinely do you do the following?

 

 

Never

 
Sometimes

 

Always

1.      Try to avoid getting sick (e.g., wash your hands)?

1

2

3

4

5

2.      Get some exercise (e.g., take a brisk walk, use the stairs)?

         1

2

3

4

5

3.      Eat a low salt diet?

1

2

3

4

5

4.      See your health care provider for routine health care?

1

2

3

4

5

5.      Take prescribed medicines without missing a dose?

1

2

3

4

5

6.      Order low salt items when eating out?

1

2

3

4

5

7.      Make sure to get a flu shot annually?

1

2

3

4

5

8.      Ask for low salt foods when visiting family and friends?

1

2

3

4

5

9.      Use a system or method to help you remember to take your medicines?

1

2

3

4

5

10. Ask your healthcare provider about your medicines?

1

2

3

4

5

 

SECTION B:

Listed below are changes that people with heart failure commonly monitor. How often do you do the following?

 

 

Never

 
Sometimes

 

Always

11. Monitor your weight daily?

1

2

3

4

5

12. Pay attention to changes in how you feel?

1

2

3

4

5

13. Look for medication side-effects?

1

2

3

4

5

14. Notice whether you tire more than usual doing normal activities?

1

2

3

4

5

15. Ask your healthcare provider how you’re doing?

1

2

3

4

5

16. Monitor closely for symptoms?

1

2

3

4

5

17. Check your ankles for swelling?

1

2

3

4

5

18. Check for shortness of breath with activity such as bathing and dressing?

1

2

3

4

5

19. Keep a record of symptoms?

1

2

3

4

5

The last time you had symptoms…

(circle one number)

 

Have not had symptoms

I did not recognize the symptom

Not Quickly

 

Somewhat Quickly

 

Very Quickly

20. How quickly did you recognize that you had symptoms?

N/A

0

1

2

3

4

5

21. How quickly did you know that the symptom was due to heart failure?

N/A

0

1

2

3

4

5

 

 

SECTION C:

Listed below are behaviors that people with heart failure use to control their symptoms. When you have symptoms, how likely are you to use one of these?

 

(circle one number for each treatment)

 

Not Likely

 

Somewhat Likely

 

Very Likely

22. Further limit the salt you eat that day?

1

2

3

4

5

23. Reduce your fluid intake?

1

2

3

4

5

24. Take a medicine?

1

2

3

4

5

25. Call your healthcare provider for guidance?

1

2

3

4

5

26. Ask a family member or friend for advice?

1

2

3

4

5

27. Try to figure out why you have symptoms?

1

2

3

4

5

28.  Limit your activity until you feel better?

1

2

3

4

5

 

 

Think of a treatment you used the last time you had symptoms… (circle one number)

 

 

I did not do anything

Not Sure

 

Somewhat Sure

 

Very Sure

29. Did the treatment you used make you feel better?

0

1

2

3

4

5

 

SECTION D:

In general, how confident are you that you can:

(Circle one number for each statement)

 

Not Confident

 

SomewhatConfident

 

Extremely Confident

30. Keep yourself stable and free of symptoms?

1

2

3

4

5

31.             Follow the treatment plan you have been given?

1

2

3

4

5

32.  Persist in following the treatment plan   even when difficult?

1

2

3

4

5

33.             Monitor your condition routinely?

1

2

3

4

5

34.             Persist in routinely monitoring your condition even when difficult?

1

2

3

4

5

35.       Recognize changes in your health if they occur?

1

2

3

4

5

36.             Evaluate the importance of your symptoms?

1

2

3

4

5

37.       Do something to relieve your symptoms?

1

2

3

4

5

38.       Persist in finding a remedy for your symptoms even when difficult?

1

2

3

4

5

39.       Evaluate how well a remedy works?

1

2

3

4

5

 

THANK YOU FOR COMPLETING THIS SURVEY!