Which of the following lifestyle changes have you made or experienced due to your HCM?
Check all that apply:
The following questions ask you to report on your experiences with HCM during the past 7 days. Please check one box per question that best describes your symptom during that time. Please be sure to answer all questions.
Were you short of breath during the past 7 days?
Select one:
Were you short of breath during light physical activity such as
walking slowly or cooking during the past 7 days?
Select one:
Were you short of breath during moderate physical activity such
as cleaning house or lifting heavy objects during the past 7
days?
Select one:
How often did you have shortness of breath during the past 7
days?
Select one:
The following questions ask you to report on your experiences with HCM during the past 7 days. Please check one box per question that best describes your symptom during that time. Please be sure to answer all questions.
Were you tired during the past 7 days?
Select one:
Did your heart beat rapidly or flutter (palpitations) during
the past 7 days?
Select one:
Did you have chest pain during the past 7 days?
Select one:
Were you dizzy or lightheaded during the past 7 days?
Select one:
Did you faint or lose consciousness during the past 7 days?
Select one:
Thank you for using the interactive HCM Symptom Questionnaire
Now that you’ve completed the Symptom Questionnaire, you can access this information and bring it with you to discuss with your cardiologist.
For your convenience, you can access your information in any of the following ways:
© 2020 MyoKardia, Inc. MyoKardia, a Bristol Myers Squibb company, maintains version control of the scale and all future iterations of the HCM Symptom Questionnaire.