CC-SCHFI V3 (English)

Adapted by

Ercole Vellone, PhD, RN, FESC

Associate Professor in Nursing Science

Department of Biomedicine and Prevention
University of Rome “Tor Vergata”,
Via Montpellier, 1 – 00133 Rome, Italy
Phone + 39 06 72596802
Fax + 39 0672596961
Mobile + 393387491811
Skype: ercole.vellone
email: ercole.vellone@uniroma2.it
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CAREGIVER CONTRIBUTION TO SELF-CARE OF HEART FAILURE INDEX Version 3 All answers are confidential DATE: ID: Please answer the following questions about what you do for the person with heart failure. Answer honestly, there are no right or wrong answers. How often do you provide support, assistance, or advice to the person you care for in carrying out the following activities? (All activities refer to the person you care for, not to you as a caregiver) SECTION A: Never Sometimes Always 1. Try to avoid getting sick (e.g., wash 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 in 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 him/her remember to take their 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 some changes that people with heart failure typically monitor. How often do you as a caregiver provide support, assistance, or advice to carry out the following? (All activities refer to the person you care for, not to you as a caregiver) Never Sometimes Always 9. Monitor for changes in weight or ankle swelling? 1 2 3 4 5 10. Pay attention to changes in how he/she feels? 1 2 3 4 5 11. Look for medication side-effects? 1 2 3 4 5 12. Notice whether he/she tires more than usual doing normal activities? 1 2 3 4 5 13. Ask your healthcare provider how she/he is doing? 1 2 3 4 5 14. Monitor closely for symptoms? 1 2 3 4 5 15. Track 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 the person you care for had symptoms… No symptoms Did not recognize the symptoms Not quickly Fairly quickly Very quickly How quickly did you recognize that he/she 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 some behaviors that people with heart failure use to manage symptoms. When the person you care for has symptoms, how likely are you to provide support, assistance, or advice regarding the following behaviors? Unlikely Fairly likely Very likely 17. Change what he/she eats or drinks 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 his/her activity until he/she feels better? 1 2 3 4 5 Think about what you did the last time the person you care for had symptoms… Did nothing Not at all Somewhat A lot 23. Did the treatment you used make him/her feel better? 0 1 2 3 4 5 THANK YOU FOR COMPLETING THE QUESTIONNAIRE!