Kccq 12 Questionnaire Form PDF Details

If you are a patient suffering from any type of cardiovascular disease, the KCCQ 12 questionnaire form may be something that you have encountered. This form is an important tool in helping doctors diagnose and treat cardiac patients effectively by assessing their quality of life through answering questions about their health and lifestyle. By completing this questionnaire, patients can provide valuable information to healthcare professionals which in turn allows them to develop an appropriate treatment plan tailored to a patient’s individual needs. In this blog post we will discuss what the KCCQ 12 questionnaire form is, how it works, why it’s important for healthcare providers and patients alike, as well as its potential benefits. Read on if you'd like to learn more!

QuestionAnswer
Form NameKccq 12 Questionnaire Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameskccq questionnaire pdf, how to calculate kccq 12 score, kccq 12 calculator, kccq 23 questionnaire pdf

Form Preview Example

Kansas City Cardiomyopathy Questionnaire (KCCQ-12)

The following questions refer to your heart failure and how it may affect your life. Please read and complete the following questions. There are no right or wrong answers. Please mark the answer that best applies to you.

1.Heart failure affects different people in different ways. Some feel shortness of breath while others feel fatigue. Please indicate how much you are limited by heart failure (shortness of breath or fatigue) in your ability to do the following activities over the past 2 weeks.

 

 

 

 

 

 

 

Limited for

 

 

 

 

 

 

 

 

other reasons

 

 

 

Extremely

Quite a bit

Moderately

Slightly

Not at all

or did not do

 

 

Activity

Limited

Limited

Limited

Limited

Limited

the activity

 

 

a. Showering/bathing

O

O

O

O

O

O

 

 

b. Walking 1 block on

O

O

O

O

O

O

 

 

level ground

 

 

 

 

 

 

 

 

 

 

c. Hurrying or jogging

O

O

O

O

O

O

 

 

(as if to catch a bus)

 

 

 

 

 

 

 

 

 

 

 

1

2

3

4

5

6

 

 

 

 

 

 

 

 

 

 

2.Over the past 2 weeks, how many times did you have swelling in your feet, ankles or legs when you woke up in the morning?

 

3 or more times

 

 

 

 

per week but

 

Less than

Never over the

Every morning

not every day

1-2 times per week

once a week

past 2 weeks

O

O

O

O

O

1

2

3

4

5

 

 

 

 

 

3. Over the past 2 weeks, on average, how many times has fatigue limited your ability to do what you wanted?

 

 

 

3 or more times

 

 

 

All of

Several times

At least

per week but

1-2 times

Less than

Never over the

the time

per day

once a day

not every day

per week

once a week

past 2 weeks

O

O

O

O

O

O

O

1

2

3

4

5

6

7

 

 

 

 

 

 

 

4. Over the past 2 weeks, on average, how many times has shortness of breath limited your ability to do what you wanted?

 

 

 

3 or more times

 

 

 

All of

Several times

At least

per week but

1-2 times

Less than

Never over the

the time

per day

once a day

not every day

per week

once a week

past 2 weeks

O

O

O

O

O

O

O

1

2

3

4

5

6

7

 

 

 

 

 

 

 

5.Over the past 2 weeks, on average, how many times have you been forced to sleep sitting up in a chair or with at least 3 pillows to prop you up because of shortness of breath?

 

3 or more times

 

 

 

 

per week but

1-2 times

Less than

Never over the

Every night

not every day

per week

once a week

past 2 weeks

O

O

O

O

O

1

2

3

4

5

Rev. 2012-04-11

KCCQ-12

Page 2 of 2

6. Over the past 2 weeks, how much has your heart failure limited your enjoyment of life?

It has extremely

It has limited my

It has moderately

It has slightly

It has not limited

limited my enjoyment

enjoyment of life

limited my enjoyment

limited my enjoyment

my enjoyment

of life

quite a bit

of life

of life

of life at all

O

O

O

O

O

1

2

3

4

5

 

 

 

 

 

7. If you had to spend the rest of your life with your heart failure the way it is right now, how would you feel about this?

Not at all

Mostly

Somewhat

Mostly

Completely

satisfied

dissatisfied

satisfied

satisfied

satisfied

O

O

O

O

O

1

2

3

4

5

 

 

 

 

 

8.How much does your heart failure affect your lifestyle? Please indicate how your heart failure may have limited your participation in the following activities over the past 2 weeks.

 

 

 

 

 

 

Does not apply

 

Severely

Limited

Moderately

Slightly

Did not or did not do for

Activity

Limited

quite a bit

limited

limited

limit at all

other reasons

a. Hobbies, recreational

O

O

O

O

O

O

activities

 

 

 

 

 

 

b. Working or doing

O

O

O

O

O

O

household chores

 

 

 

 

 

 

c. Visiting family or

 

 

 

 

 

 

friends out of your

O

O

O

O

O

O

home

 

 

 

 

 

 

 

1

2

3

4

5

6

Rev. 2012-04-16

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2. Once your current task is complete, take the next step – fill out all of these fields - the time, per day, once a day, per week but not every day, times per week, once a week, Never over the past weeks, Over the past weeks on average, least pillows to prop you up, Every night, or more times, per week but not every day, times per week, Less than, and once a week with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

kansas city cardiomyopathy questionnaire completion process explained (portion 2)

3. Within this part, look at of life, quite a bit, of life, of life, of life at all, If you had to spend the rest of, Not at all satisfied, Mostly, dissatisfied, Somewhat, satisfied, Mostly satisfied, Completely, satisfied, and How much does your heart failure. Each one of these should be taken care of with greatest accuracy.

kansas city cardiomyopathy questionnaire completion process clarified (portion 3)

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