Heart Failure Care Plan Form
Document and plan care for patients with heart failure. Please complete all relevant sections for a comprehensive care plan.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Diagnosis or Heart Failure Stage/Class
*
Please Select
Heart Failure with Reduced Ejection Fraction (HFrEF)
Heart Failure with Preserved Ejection Fraction (HFpEF)
NYHA Class I
NYHA Class II
NYHA Class III
NYHA Class IV
Other
Current Symptoms (select all that apply)
Shortness of breath
Fatigue
Swelling in legs/ankles (edema)
Rapid weight gain
Chest pain
Palpitations
Dizziness or fainting
Other
Current Medications and Doses
*
Known Allergies or Medication Reactions
Recent Weight Change (lbs/kg) and Edema Status
Blood Pressure (mmHg) and Heart Rate (bpm)
Care Goals or Instructions for the Care Plan
*
Follow-Up Date or Next Appointment
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Care Plan
Should be Empty: