Self-Care of Heart Failure Index English Version 8.0

Authored by

Barbara Riegel, PhD, RN, FAAN, FAHA

Professor

University of Pennsylvania, School of Nursing
Claire M. Fagin Hall, 418 Curie Boulevard
Philadelphia, PA 19104-4217
briegel@nursing.upenn.edu
215-898-9927 Phone
240-282-7707 eFax
Co-Director, International Center for Self-Care Research www.selfcareresearch.org

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SELF-CARE OF HEART FAILURE INDEX

Version 8.0

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, keep vaccinations up to date)?	1	2	3	4	5
2. Reduce time sitting?	1	2	3	4	5
3. Eat healthy and avoid foods that are high is salt?	1	2	3	4	5
4. Take prescribed medicines without missing a dose?	1	2	3	4	5
5. Balance rest and activity?	1	2	3	4	5
6. Make sure to get enough sleep?	1	2	3	4	5
7. Use a system or method to help you remember to take your medicines?	1	2	3	4	5
8. Maintain good mental health (e.g. music mindfulness, yoga, seek professional help)?	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
9. Monitor for changes in your weight or ankle swelling?	1	2	3	4	5
10. Pay attention to changes in how you feel?	1	2	3	4	5
11. Look for medication side-effects?	1	2	3	4	5
12. Notice whether you tire more than usual doing normal activities?	1	2	3	4	5
13. Ask your healthcare provider how youre doing?	1	2	3	4	5
14. Monitor closely for symptoms?	1	2	3	4	5
15. Track your mood and stress level?	1	2	3	4	5
16. Check for shortness of breath or fatigue with activities like bathing and dressing?	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
How quickly did you recognize that you had symptoms?	N/A	0	1	2	3	4	5
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
17. Change what you eat or drink that day?	1	2	3	4	5
18. Do something to relieve stress or anxiety (e.g., mindfulness, music, prayer, seek help)?	1	2	3	4	5
19. Take a medicine?	1	2	3	4	5
20. Call your healthcare provider for guidance?	1	2	3	4	5
21. Ask a family member or friend for advice?	1	2	3	4	5
22. 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
23. Did the treatment you used make you feel better?	0	1	2	3	4	5

THANK YOU FOR COMPLETING THIS SURVEY!