The Purple Book

Heart Failure tracker

Leg swelling

This is swelling that you can push your finger into. Select ONE

I don't have any swelling

Only my ankles are swollen

Swelling to between ankles and knees

Swelling to knee area

Swelling above knees below my hips

Swelling all the way to hips

Daily functions

Select ONE

Breathing does NOT stop me leaving the house

Something else stops me leaving the house

Breathing problems stop me leaving the house

Hard moving about house because of breathing problems

Dressing, bathing makes me breathless

Sleeping position

related to your breathing only. Select ONE

Can lie flat to sleep

Need 1 pillow to sleep

Need 2 pillows to sleep

Need 3 pillows to sleep

Can only sleep sitting upright or in chair

Something else stops me lying flat

Sleep disturbance

related to your breathing only. Select ONE

Breathing problems do NOT wake me

Waking once or twice because of my breathing

Waking more than twice because of my breathing

Perceived exertion while walking

ONLY related to your breathing: Select ONE

Unable to walk but NOT because of breathing problems

Can walk and talk easily as long as I like

Breathe heavily but can still talk

Breathe heavily and hard to talk

Breathe heavily and keep stopping to catch breath

Exercise capacity

This is only if you have agreed a 5 minute test distance. Select ONE

Don't have an agreed distance plan

Can walk at least 6 laps of agreed distance

Can walk 5 laps of agreed distance

Can walk 4 laps of agreed distance

Can walk 3 laps of agreed distance

Can walk 2 laps of agreed distance

Can walk agreed distance only ONCE

Fluid Restriction

I am NOT on Fluid Restriction

I have been sticking to the Fluid Restriction amount

I am drinking MORE than the Fluid Restriction amount

I am drinking LESS than the Fluid Restriction amount

Overall feeling

Select ONE that fits best

Better than yesterday

SAME as yesterday

Worse than yesterday

Your Vital Signs readings:

these are optional - discuss with the Team

systolic Blood Pressure

diastolic Blood Pressure

Heart Rate

Oxygen saturation (%)

Temperature

Weight (kg)

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