Kccq 12 Questionnaire Form PDF Details

The Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) represents a concise yet comprehensive tool designed to evaluate the impact of heart failure on an individual's daily life and well-being. Through a series of detailed inquiries, this questionnaire delves into the different dimensions of health that can be affected by heart failure, including physical limitations, symptoms (such as shortness of breath and fatigue), social function, and the psychological toll taken by the disease. Respondents are asked to reflect on their experiences over the prior two weeks, marking answers that best describe their condition across a spectrum of activities and feelings. This methodical approach offers clinicians a nuanced understanding of how heart failure impedes upon the lives of those affected, turning subjective health narratives into quantifiable data. This data, in turn, serves as a critical component in tailoring patient care, informing treatment plans, and measuring outcomes in both clinical and research contexts. Updated last in April 2012, the KCCQ-12 continues to stand as a pivotal instrument in cardiovascular health assessment, striking a balance between brevity and in-depth patient insight.

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

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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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