Angina Assessment Form
Please complete the Angina Assessment Form to help us understand your recent experiences with angina symptoms. Your responses will assist in evaluating the frequency, severity, and impact of your symptoms.
How often have you experienced chest discomfort or pain in the past two weeks?
*
Never
Rarely (1-2 times)
Occasionally (3-5 times)
Frequently (more than 5 times)
When do your symptoms most commonly occur?
*
During physical activity
At rest
After eating
During emotional stress
Other
How would you rate the severity of your chest discomfort or pain?
*
1
2
3
4
5
How long does a typical episode of chest discomfort or pain last?
*
Less than 1 minute
1-5 minutes
6-10 minutes
More than 10 minutes
What typically relieves your chest discomfort or pain?
*
Rest
Medication
Deep breathing
Nothing in particular
Other
Please indicate how much the following symptoms have affected you in the past two weeks.
*
Rows
Not at all
A little
Moderately
Severely
Shortness of breath
1
2
3
4
Fatigue
5
6
7
8
Nausea
9
10
11
12
Sweating
13
14
15
16
Have your symptoms limited your ability to perform daily activities?
*
Not at all
A little
Moderately
Significantly
Have you noticed any new or worsening symptoms recently?
*
Yes
No
If yes, please describe any new or worsening symptoms.
Do you have any additional comments or information regarding your angina symptoms?
Submit Assessment
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