MY APPOINTMENT DIARY - Pumping Marvellous Foundation · YOUR APPOINTMENT DIARY Feeling okay today - no change from last time. I’m not sure, maybe it’s just one of those days.
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MY APPOINTMENT
DIARY
Help in managing your heart failure
How are you feeling today?
YOUR APPOINTMENT DIARY
Feeling okay today - no change from last time.
I’m not sure, maybe it’s just one of those days.
I don’t feel like things are going as well as last time.
Where are you in New York?NYHA Class Symptoms
NYHA Class 1 No limitation of physical activity. Ordinary physical activity does not cause undue tiredness, palpitations, or shortness of breath. Referred to as NHYA 1.
NYHA Class 2 Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in tiredness, palpitations, or shortness of breath. Referred to as NHYA 2.
NYHA Class 3 Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes tiredness, palpitations or shortness of breath. Referred to as NHYA 3.
NYHA Class 4 Unable to carry out any physical activity without discomfort and tired and short of breath even at rest. If any physical activity is undertaken, discomfort increases. Referred to as NHYA 4.
Discussion pointsWhat do you feel are the priorities for your appointment? Write them down so you can discuss them
with your Healthcare Professional. Make sure you set your next appointment and write it in your diary.
Use this diary in conjunction with ‘My Marvellous Symptom Checker.’
2
HOW ARE YOU FEELING?DATE:
DISCUSSION POINTS
YOUR NEXT APPOINTMENT
AT:
DATE: TIME:
NYHA 1 NYHA 3
NYHA 2 NYHA 4
Red
Amber
Green
(See your ‘My Marvellous Symptom Checker’ or refer to page 2 of this booklet).
3
DATE:
DISCUSSION POINTS
YOUR NEXT APPOINTMENT
AT:
DATE: TIME:
HOW ARE YOU FEELING?
NYHA 1 NYHA 3
NYHA 2 NYHA 4
Red
Amber
Green
(See your ‘My Marvellous Symptom Checker’ or refer to page 2 of this booklet).
4
DATE:
DISCUSSION POINTS
YOUR NEXT APPOINTMENT
AT:
DATE: TIME:
HOW ARE YOU FEELING?
NYHA 1 NYHA 3
NYHA 2 NYHA 4
Red
Amber
Green
(See your ‘My Marvellous Symptom Checker’ or refer to page 2 of this booklet).
5
DATE:
DISCUSSION POINTS
YOUR NEXT APPOINTMENT
AT:
DATE: TIME:
HOW ARE YOU FEELING?
NYHA 1 NYHA 3
NYHA 2 NYHA 4
Red
Amber
Green
(See your ‘My Marvellous Symptom Checker’ or refer to page 2 of this booklet).
6
DATE:
DISCUSSION POINTS
YOUR NEXT APPOINTMENT
AT:
DATE: TIME:
HOW ARE YOU FEELING?
NYHA 1 NYHA 3
NYHA 2 NYHA 4
Red
Amber
Green
(See your ‘My Marvellous Symptom Checker’ or refer to page 2 of this booklet).
7
DATE:
DISCUSSION POINTS
YOUR NEXT APPOINTMENT
AT:
DATE: TIME:
HOW ARE YOU FEELING?
NYHA 1 NYHA 3
NYHA 2 NYHA 4
Red
Amber
Green
(See your ‘My Marvellous Symptom Checker’ or refer to page 2 of this booklet).
8
DATE:
DISCUSSION POINTS
YOUR NEXT APPOINTMENT
AT:
DATE: TIME:
HOW ARE YOU FEELING?
NYHA 1 NYHA 3
NYHA 2 NYHA 4
Red
Amber
Green
(See your ‘My Marvellous Symptom Checker’ or refer to page 2 of this booklet).
9
DATE:
DISCUSSION POINTS
YOUR NEXT APPOINTMENT
AT:
DATE: TIME:
HOW ARE YOU FEELING?
NYHA 1 NYHA 3
NYHA 2 NYHA 4
Red
Amber
Green
(See your ‘My Marvellous Symptom Checker’ or refer to page 2 of this booklet).
10
DATE:
DISCUSSION POINTS
YOUR NEXT APPOINTMENT
AT:
DATE: TIME:
HOW ARE YOU FEELING?
NYHA 1 NYHA 3
NYHA 2 NYHA 4
Red
Amber
Green
(See your ‘My Marvellous Symptom Checker’ or refer to page 2 of this booklet).
11
DATE:
DISCUSSION POINTS
YOUR NEXT APPOINTMENT
AT:
DATE: TIME:
HOW ARE YOU FEELING?
NYHA 1 NYHA 3
NYHA 2 NYHA 4
Red
Amber
Green
(See your ‘My Marvellous Symptom Checker’ or refer to page 2 of this booklet).
12
DATE:
DISCUSSION POINTS
YOUR NEXT APPOINTMENT
AT:
DATE: TIME:
HOW ARE YOU FEELING?
NYHA 1 NYHA 3
NYHA 2 NYHA 4
Red
Amber
Green
(See your ‘My Marvellous Symptom Checker’ or refer to page 2 of this booklet).
13
DATE:
DISCUSSION POINTS
YOUR NEXT APPOINTMENT
AT:
DATE: TIME:
HOW ARE YOU FEELING?
NYHA 1 NYHA 3
NYHA 2 NYHA 4
Red
Amber
Green
(See your ‘My Marvellous Symptom Checker’ or refer to page 2 of this booklet).
14
DATE:
DISCUSSION POINTS
YOUR NEXT APPOINTMENT
AT:
DATE: TIME:
HOW ARE YOU FEELING?
NYHA 1 NYHA 3
NYHA 2 NYHA 4
Red
Amber
Green
(See your ‘My Marvellous Symptom Checker’ or refer to page 2 of this booklet).
15
Keep track of your measurements here - it will help you determine if you have gained or lost any
weight rapidly and help you work out if you need to contact your Healthcare Professional about it.
DATE WEIGHTTRAFFIC LIGHT (See your ‘My Marvellous Symptom Checker)
NYHA(See Page 1)
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
MEASUREMENTS
16
DATE WEIGHTTRAFFIC LIGHT (See your ‘My Marvellous Symptom Checker)
NYHA(See Page 1)
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
MEASUREMENTS
17
MEASUREMENTSDATE WEIGHT
TRAFFIC LIGHT (See your ‘My Marvellous Symptom Checker)
NYHA(See Page 1)
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
18
MEASUREMENTSDATE WEIGHT
TRAFFIC LIGHT (See your ‘My Marvellous Symptom Checker)
NYHA(See Page 1)
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
19
MEASUREMENTSDATE WEIGHT
TRAFFIC LIGHT (See your ‘My Marvellous Symptom Checker)
NYHA(See Page 1)
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
20
MEASUREMENTSDATE WEIGHT
TRAFFIC LIGHT (See your ‘My Marvellous Symptom Checker)
NYHA(See Page 1)
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
21
MEASUREMENTSDATE WEIGHT
TRAFFIC LIGHT (See your ‘My Marvellous Symptom Checker)
NYHA(See Page 1)
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
22
MEASUREMENTSDATE WEIGHT
TRAFFIC LIGHT (See your ‘My Marvellous Symptom Checker)
NYHA(See Page 1)
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
23
MEASUREMENTSDATE WEIGHT
TRAFFIC LIGHT (See your ‘My Marvellous Symptom Checker)
NYHA(See Page 1)
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
24
MEASUREMENTSDATE WEIGHT
TRAFFIC LIGHT (See your ‘My Marvellous Symptom Checker)
NYHA(See Page 1)
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
25
MEASUREMENTSDATE WEIGHT
TRAFFIC LIGHT (See your ‘My Marvellous Symptom Checker)
NYHA(See Page 1)
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
26
MEASUREMENTSDATE WEIGHT
TRAFFIC LIGHT (See your ‘My Marvellous Symptom Checker)
NYHA(See Page 1)
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
RedAmberGreen
1 32 4
27
HEART FAILURE MEDICINES TIME DOSE ANY SIDE EFFECTS
MO
RN
ING
AFT
ERN
OO
NB
EDT
IME
EVEN
ING
It is important to understand the medication you take to control your heart failure, if you are unsure
then why not ask your Doctor, Nurse or Pharmacist to explain what you are taking and why.
MY HEART FAILURE MEDICINES
28
HEART FAILURE MEDICINES TIME DOSE ANY SIDE EFFECTS
MO
RN
ING
AFT
ERN
OO
NB
EDT
IME
EVEN
ING
MY HEART FAILURE MEDICINES
29
HEART FAILURE MEDICINES TIME DOSE ANY SIDE EFFECTS
MO
RN
ING
AFT
ERN
OO
NB
EDT
IME
EVEN
ING
MY HEART FAILURE MEDICINES
30
HEART FAILURE MEDICINES TIME DOSE ANY SIDE EFFECTS
MO
RN
ING
AFT
ERN
OO
NB
EDT
IME
EVEN
ING
MY HEART FAILURE MEDICINES
31
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