The left ventricular dysfunction questionnaire (LVD-36)
| Please answer the following questions as you are feeling these days. Tick either true or false for each question. | ||
| Because of my heart condition: | True | False |
| I suffer with tired legs | □ | □ |
| I suffer with nausea (feeling sick) | □ | □ |
| I suffer with swollen legs | □ | □ |
| Because of my heart condition: | True | False |
| I am afraid that if I go out I will be short of breath | □ | □ |
| I am frightened to do too much in case I become short of breath | □ | □ |
| I get out of breath with the least physical exercise | □ | □ |
| I am frightened to push myself too far | □ | □ |
| I take a long time to get washed or dressed | □ | □ |
| If you do not do these activities for any reason other than your heart condition, then please tick false | ||
| Because of my heart condition: | True | False |
| I have difficulty running, such as for a bus | □ | □ |
| I have difficulty either jogging, exercising or dancing | □ | □ |
| I have difficulty playing with children/grandchildren | □ | □ |
| I have difficulty either mowing the lawn or hoovering/vacuum cleaning | □ | □ |
| Because of my heart condition: | True | False |
| I feel exhausted | □ | □ |
| I feel low in energy | □ | □ |
| I feel sleepy or drowsy | □ | □ |
| I need to rest more | □ | □ |
| I feel that everything is an effort | □ | □ |
| My muscles feel weak | □ | □ |
| I get cold easily | □ | □ |
| I wake up frequently during the night | □ | □ |
| I have become frail or an invalid | □ | □ |
| Because of my heart condition: | True | False |
| I feel frustrated | □ | □ |
| I feel nervous | □ | □ |
| I feel irritable | □ | □ |
| I feel restless | □ | □ |
| I feel out of control of my life | □ | □ |
| I feel that I can not enjoy a full life | □ | □ |
| I've lost confidence in myself | □ | □ |
| Because of my heart condition: | True | False |
| I have difficulty having a regular social life | □ | □ |
| There are places I would like to go to but can't | □ | □ |
| I worry that going on holiday could make my heart condition worse | □ | □ |
| I have had to alter my lifestyle | □ | □ |
| I am restricted in fulfilling my family duties | □ | □ |
| I feel dependent on others | □ | □ |
| True | False | |
| I find it a real nuisance having to take tablets for my heart condition | □ | □ |
| My heart condition stops me doing things that I would like to do | □ | □ |
PLEASE CHECK THAT YOU HAVE ANSWERED ALL THE QUESTIONS
THANK YOU FOR YOUR TIME