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Real HCM Stories
Symptom Questionnaire

Lifestyle Changes

Which of the following lifestyle changes have you made or experienced due to your HCM?
Check all that apply:

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Symptoms of HCM

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:

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Symptoms of HCM

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:

Your HCM Symptom Questionnaire Results

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:

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