Atrial Fibrillation Assessment Questionnaire Form
Please complete this questionnaire to help assess symptoms and impact related to atrial fibrillation. All responses are confidential and for informational purposes only.
Full Name
*
First Name
Last Name
Have you ever been diagnosed with atrial fibrillation by a healthcare provider?
*
Yes
No
Not sure
How often do you experience symptoms that may be related to atrial fibrillation (such as palpitations, irregular heartbeat, or fluttering)?
*
Daily
Several times a week
Once a week or less
Rarely or never
Please rate the severity of the following symptoms in the past month.
*
Rows
None
Mild
Moderate
Severe
Palpitations (irregular or rapid heartbeat)
1
2
3
4
Shortness of breath
5
6
7
8
Fatigue or weakness
9
10
11
12
Dizziness or lightheadedness
13
14
15
16
Have you ever experienced any of the following conditions? (Select all that apply)
*
High blood pressure
Heart disease
Diabetes
Sleep apnea
Thyroid problems
None of the above
How much do your symptoms interfere with your daily activities?
*
Not at all
1
2
3
4
Extremely
5
1 is Not at all, 5 is Extremely
Do you currently take any medications to manage atrial fibrillation?
*
Yes
No
Not sure
How would you rate your overall quality of life in the past month?
*
1
2
3
4
5
Is there anything else you would like to share regarding your symptoms or atrial fibrillation experience?
Submit Assessment
Should be Empty: