LIVING WITH HEART FAILURE QUESTIONNAIRE

Instructions for Use

1. Patients should respond to the questionnaire prior to other assessments and interactions
that may bias responses. You may tell the patient that you would like to get his or her
opinion before doing other medical assessments.

2. Ample, uninterrupted time should be provided for the patient to complete the
questionnaire.

3. The following instructions should be given to the patient each time the questionnaire is
completed.

a. Read the introductory paragraph at the top of the questionnaire to the patient.

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b. Read the first question to the patient - "Did your heart failure prevent you from
living as you wanted during the past month by causing swelling in your ankles or

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legs"? Tell the patient, "If you did not have any ankle or leg swelling during the

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past month you should circle the zero after this question to indicate that swelling

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co t pe
was not a problem during the past month". Explain to the patient that if he or she
did have swelling that was caused by a sprained ankle or some other cause that
was definitely not related to heart failure he or she should also circle the zero.

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Tell the patient, "If you are not sure why you had the swelling or think it was

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related to your heart condition, then rate how much the swelling prevented you

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from doing things you wanted to do and from feeling the way you would like to
feel". In other words, how bothersome was the swelling? Show the patient how to

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use the 1 to 5 scale to indicate how much the swelling affected his or her life

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during the past month - from very little to very much.

4.
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Let the patient read and respond to the other questions. The entire questionnaire may be

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read directly to the patient if one is careful not to influence responses by verbal or

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physical cues.

5.

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Check to make sure the patient has responded to each question and that there is only one
answer clearly marked for each question. If a patient elects not to answer a specific
question(s) indicate so on the questionnaire.

6. Score the questionnaire by summating the responses to all 21 questions. In addition,

physical (items 2, 3, 4, 5, 6, 7, 12 and 13) and emotional (items 17, 18, 19, 20, and 21)
dimensions of the questionnaire have been identified by factor analysis, and may be
examined to further characterize the effect of heart failure on a patient's life.

MLHF – USA/English
MLHF_AU2.0_eng-USori.doc
 LIVING WITH HEART FAILURE QUESTIONNAIRE
These questions concern how your heart failure (heart condition) has prevented you from living as you
wanted during the last month. The items listed below describe different ways some people are affected. If
you are sure an item does not apply to you or is not related to your heart failure then circle 0 (No) and go
on to the next item. If an item does apply to you, then circle the number rating how much it prevented you
from living as you wanted.

Did your heart failure prevent you from

living as you wanted during the last
month by:

No Very Very
little much
1. Causing swelling in your ankles, legs, 0 1 2 3 4 5

n
etc.?

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2. Making you sit or lie down to rest during 0 1 2 3 4 5
the day?

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s
3. Making your walking about or climbing 0 1 2 3 4 5

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stairs difficult?

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4. Making your working around the house 0 1 2 3 4 5
or yard difficult?
5. Making your going places away from
home difficult?
co t pe
0r 1 2 3 4 5

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6. Making your sleeping well at night 0 1 2 3 4 5
difficult?
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7. Making your relating to or doing things
o 0 1 2 3 4 5

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with your friends or family difficult?

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8. Making your working to earn a living 0 1 2 3 4 5
difficult?

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9. Making your recreational pastimes, sports 0 1 2 3 4 5

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or hobbies difficult?
10. Making your sexual activities difficult? 0 1 2 3 4 5

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11. Making you eat less of the foods you 0 1 2 3 4 5

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like?
12. Making you short of breath? 0 1 2 3 4 5

energy?
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13. Making you tired, fatigued, or low on

14. Making you stay in a hospital?

0

0
1

1
2

2
3

3
4

4
5

5
15. Costing you money for medical care? 0 1 2 3 4 5
16. Giving you side effects from 0 1 2 3 4 5
medications?
17. Making you feel you are a burden to your 0 1 2 3 4 5
family or friends?
18. Making you feel a loss of self-control in 0 1 2 3 4 5
your life?
19. Making you worry? 0 1 2 3 4 5
20. Making it difficult for you to concentrate 0 1 2 3 4 5
or remember things?
21. Making you feel depressed? 0 1 2 3 4 5
Copyright University of Minnesota 1986.

MLHF – USA/English
MLHF_AU2.0_eng-USori.doc