Self Care Behavior

None

of the

Time

A

little

of

the

Time

Some of the Time

A

 Good Bit of the Time

Most of the Time

All of

the

Time

1. I weigh myself on every day of  

    the week.

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2

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4

5

2.  When I am short of breath, I

     rest.

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4

5

3.  When I am short of breath or

     tired, I ask for help with  

     something I am unable to do.

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1

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5

4. I contact my doctor when I

   feel more short of breath.

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1

2

3

4

5

5. I contact my doctor when I see

    my feet, ankles, legs or

    stomach swell.

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1

2

3

4

5

6. I contact my doctor when I

    have gained 2 pounds or more

    in a day, or 3 pounds or more

    since my last visit to the doctor.

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1

2

3

4

5

7. I watch how much water I pass

   (urinate or pee) each day.

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1

2

3

4

5

8. I am careful not to drink “too

    many” fluids.

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2

3

4

5

9. When I feel anxious about my

    worsening symptoms of heart

    failure I talk with my doctor

    about it.

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3

4

5

10.  I contact my doctor when I

       have nausea or do not feel 

       like eating.

0

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3

4

5

11. To help reduce my symptoms,

       like fatigue or shortness of

       breath, I limit the activities

       that are hard to me.

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5

12.  I believe that having heart

       failure is a condition that I

       can adjust to.

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5

Self Care Behavior

None

of the

Time

A

little

of

the

Time

Some of the Time

A

 Good Bit of the Time

Most of the Time

All of

the

Time

13.  I spread my activities out

       over  the whole day so I do 

       not get tired.

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1

2

3

4

5

14.  I plan rest times during my

       day.

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2

3

4

5

15.  I contact my doctor when I

       realize I am feeling tired all

      the time.

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1

2

3

4

5

16.  I watch that I do not eat

       canned soups or TV dinners.

0

1

2

3

4

5

17.  I take my pills every day.

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3

4

5

18.  I take my pills as the doctor

       prescribed – I take all the

       doses of my pills.

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1

2

3

4

5

19.  I always refill prescriptions

       for my pills on time.

0

1

2

3

4

5

20.  I have a system to help tell

       me when to take my pills.

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2

3

4

5

21.  I stay away from people who

       have a cold or flu.

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1

2

3

4

5

22.  I am physically active (for

       example, walk or ride a bike)

       on 3 to 4 days per week.

0

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2

3

4

5

23.  I get a flu shot once a year.

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3

4

5

24.  I limit my alcohol intake to

       one glass of beer or wine, or

       one shot a day.

0

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2

3

4

5

25.  I am a non-smoker.

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3

4

5

26.  I keep my appointments with

       my doctor.

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3

4

5

27.  I put my feet up when I sit in

       a chair.

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1

2

3

4

5

28.  I talk to my doctor and family

       about my condition in order

       to make choices and plans for

       the future.

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5

29.  I think a person can live a

       happy and good life even

       after having heart failure.

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4

5