Cardiff Cardiac Ablation PROM (C-CAP2)
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- Iris Reeves
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1 Arrhythmia Questionnaire After your Operation We would be grateful if you could give us some feedback on how you have been feeling since your procedure to treat your palpitations / fast or irregular heartbeats. Please answer ALL of the questions. 1) Please tick ONE box which best describes your symptoms within the last 30 days related to the FREQUENCY of the attacks of your palpitations / fast or irregular heartbeats (i.e. how OFTEN they occur): My palpitations / fast or irregular heartbeats have: (please tick one) Stopped Become less frequent t changed Become more frequent 2) Please tick ONE box which best describes your symptoms within the last 30 days related to the LENGTH of the attacks of your palpitations / fast or irregular heartbeats (i.e. how LONG they last): The duration of my palpitations / fast or irregular heartbeats has: (please tick one) They have stopped Become shorter t changed Become longer 3) Please tick ONE box in EACH column which best describes your symptoms within the last 30 days related to your tiredness and breathlessness: I do not feel tired Please tick one I do not feel breathless Please tick one I feel less tired I feel no different (tiredness) I feel more tired I feel less breathless I feel no different (breathlessness) I feel more breathless Page 1 of 5
2 4) During your hospital stay, or in the month afterwards, did you experience any complications related to your ablation procedure? 5) Which complications (if any) were you WARNED ABOUT related to your procedure? Please tick ALL that you were warned about. ne Excessive bruising Wound site complications (eg. bleeding / swelling) Stroke Blood around the heart requiring a needle to remove it Air around the lung (pneumothorax) Extended hospital stay (related to your procedure) Readmission to hospital (related to your procedure) 6) Which complications (if any) did you EXPERIENCE related to your procedure? Please tick ALL that you experienced: complications Excessive bruising Wound site complications (e.g. bleeding / swelling) Stroke Blood around the heart requiring a needle to remove it Air around the lung (pneumothorax) Extended hospital stay (related to your procedure) Readmission to hospital (related to your procedure) Other complication related to your procedure (please specify) 7) Did the outcome of the procedure meet or exceed your expectations? Page 2 of 5
3 The following questions are related to your condition and symptoms SINCE your recent procedure 8) Please circle the numbers below that most accurately indicate the severity of each symptom you have had within the last 30 days. Please circle ONE number for EVERY symptom. If you do not have the symptom please circle 0 (ne). 0 ne 1 Mild 2 Moderate 3 Severe Palpitations / fast or irregular heartbeats Heart flutters Extra heart beats / missed heart beats Fatigue / no energy Dizziness / light-headedness / feeling faint Hard to catch breath / short of breath Chest pressure as heart is racing Headache / migraine Trouble concentrating Neck pounding / neck pain / neck discomfort Trouble sleeping Tiredness / sleepiness Nausea / vomiting Anxiety / fear / worry 9) Since your ablation, how often do you usually get palpitations / fast or irregular heartbeats? Please tick one only Never Once a month or less month week day 10) Since your ablation, how long do your episodes of palpitations / fast or irregular heartbeats usually last? Please tick one only More than 1 hour t Less than 5 minutes to 12 hours or but less than 12 Applicable 5 minutes 1 hour more hours Page 3 of 5
4 11) Have your palpitations / fast or irregular heartbeats had any impact on the number of days you have attended work / school / college (including unpaid work, role as a carer and time spent jobseeking) in the last 30 days? If so, for how many days do you think it had an impact? Days you have missed at work / school / college of Days I do not attend work/ school/ college ( ) 12) Have your palpitations / fast or irregular heartbeats had any impact on your social activities in the last 30 days, and if so, for how many days do you think it has had an impact? Days you have had to cut down on your social activities of Days 13) Have your palpitations / fast or irregular heartbeats had any impact on the number of days you have been able to carry out your normal daily activities (including household duties) in the last 30 days? If so, for how many days do you think it has had an impact? Days you have been unable to carry out normal daily activities of Days 14) How many times have you needed to visit a GP / Hospital within the last 30 days (related to your palpitations / fast or irregular heartbeats)? GP Hospital 15) Please circle the number that most accurately indicates how you feel about the following statements, please circle ONE number for EVERY statement. If you feel the statement does not apply to you please circle 0 (t Applicable). I worry that my palpitations/fast or irregular heartbeats will start 0 t Applicable 1 Mildly 2 Moderately 3 Strongly My everyday physical activities are limited My palpitations have an impact on my own sport / leisure activities I worry about the effect of my heart rhythm on my health My palpitations / fast or irregular heartbeats interfere with my social activities I am restricted in my travel / holiday plans I am less confident due to my palpitations My palpitations / fast or irregular heartbeats have an emotional / physical impact when I am driving My palpitations have an impact on my family / friends Page 4 of 5
5 16) Do you normally take any medication for your palpitations / fast or irregular heartbeat? 17) If you take medication for your palpitations / fast or irregular heartbeats is it? a) More than before the procedure b) The same as before the procedure c) Less than before the procedure The following questions are related to your GENERAL health: 18) Have you been told by a doctor that you have any of the following? (Please tick all that apply) Liver disease High blood pressure Other heart condition e.g. angina, heart attack or heart failure Diabetes Lung disease e.g. asthma, chronic bronchitis or emphysema Cancer (within the last 5 years) Leg pain when walking due to poor circulation Arthritis Kidney disease Depression Problems caused by stroke Diseases of the nervous system e.g. Parkinson s disease or multiple sclerosis Cardiff Cardiac Ablation PROM (C-CAP) post ablation questionnaire by Cedar is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License. Page 5 of 5
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Dr. Hall New Patient Paperwork Please fill out these forms completely Date of Appointment Complete the enclosed packet and bring it to the appointment along with all X Rays, MRI disc and reports. Please