HCM Symptom Tracker Results
1.a Shortness of breath - How often did the following symptoms occur?
1.b Shortness of breath - How have the following symptoms limited your ability to do what you wanted or needed to do?
2.a Tiredness or fatigue - How often did the following symptoms occur?
2.b Tiredness or fatigue - How have the following symptoms limited your ability to do what you wanted or needed to do?
3.a Rapid, fluttering or strong heartbeat - How often did the following symptoms occur?
3.b Rapid, fluttering or strong heartbeat - How have the following symptoms limited your ability to do what you wanted or needed to do?
4.a Chest pain (e.g. pressure, tightness, squeezing) - How often did the following symptoms occur?
4.b Chest pain (e.g. pressure, tightness, squeezing) - How have the following symptoms limited your ability to do what you wanted or needed to do?
5.a Feeling dizzy or light-headed - How often did the following symptoms occur?
5.b Feeling dizzy or light-headed - How have the following symptoms limited your ability to do what you wanted or needed to do?
6.a Fainting or losing consciousness - How often did the following symptoms occur?
6.b Fainting or losing consciousness - How have the following symptoms limited your ability to do what you wanted or needed to do?
7.a Swelling of the feet or ankles - How often did the following symptoms occur?
7.b Swelling of the feet or ankles - How have the following symptoms limited your ability to do what you wanted or needed to do?
1. Do you feel your HCM symptoms have affected your emotional state?
2. Have you noticed any changes in your mood or energy levels that you attribute to your HCM?
3. Do you feel you have adequate support from family, friends or healthcare professionals?
1. Performing your job
2. Standing I am able to stand for ______ minutes before I have to sit.
3. Climbing stairs I am able to climb ______ flights of stairs without pausing to rest or catching my breath.
4. Household tasks Do you often rely on outside help or loved ones for household tasks such as cooking, cleaning, washing, gardening or home maintenance?
5. Grocery shopping and errands Do you often rely on delivery services or loved ones for grocery shopping and errands?
6. Sleeping
7. Taking care of or keeping up with kids/grandkids (if applicable)
8. Hobbies, recreational activities
9. Keeping up with friends and family
10. Light walking (e.g. going on a stroll or walking a pet)
11. Rigorous walking for exercise
12. Walking uphill
13. Low impact exercise (e.g. yoga or pilates)
14. High intensity exercise (e.g. jogging or group fitness)
15. Playing a sport
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