Select the symptoms that affect you:
Chest PainShortness of breathPain in the jaw, shoulder, arm, back or above the stomachFatigue

Do you ever get symptoms like the ones you selected above when walking 1 or 2 blocks on level ground or climbing on flight of stairs at a normal pace?
YesNo

Do you feel that these symptoms limit your activities of daily living such as household chores, shopping or leisure?
YesNo

Do you ever get these symptoms at rest, after eating, or just watching television?
YesNo

Do you ever awaken at night with these symptoms?
YesNo

Have you decreased your activity in the past 6 months due to these symptoms?
YesNo

Do you avoid activity because you might get these symptoms?
YesNo

Do you take nitroglycerin tablets before certain activities to prevent these symptoms?
YesNo

Are you dissatisfied with your current quality of life because of lack of energy, symptoms, or inability to engage in your normal activities of daily living?
YesNo

Have you ever had an angioplasty or a stent?
YesNo

Have you ever had bypass surgery?
YesNo

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Cardiologist's Name:

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