Heart Failure Pre‑Screen

Answer the questions below. At the end you’ll see a result and you can optionally request follow‑up. This is not a diagnosis.

Who is filling this out?

Age

ZIP Code

Has a cardiologist told you the patient has heart failure?

Activity limitation (choose the best match)

No symptoms with ordinary activity Symptoms with mild activity (stairs, brisk walk) Symptoms with very light activity (dressing, across room) Symptoms at rest / mostly limited to bed or chair

On heart failure medications?

Despite meds, still limited by shortness of breath or fatigue?

Do you have a chest device?

EF (LVEF) if known

If unknown, leave blank. See where to find EF.

Height (inches)

Weight (lb)

Most recent blood pressure (optional)

Recent hospitalization for heart failure in the last 12 months?

Does the patient have an LVAD (heart pump)?

If the patient has an LVAD or is severely ill, urgent cardiology guidance is recommended.

Anything else to add? (optional)

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Reminder: This tool is educational and not for emergencies.