Seattle Angina Questionnaire

June 14, 2011

Name:               ________________________________________

Age:          ______________________                   gender:      __________________

Address and Contacts:         ______________________________________________________

  1. On a scale of 1 to 5 how much does your chest pain restricts you from doing the following activities based on your experience over the past four weeks.(for example if chest pain affects you too much, then write 5. If least affected, write 1. If you have not done the activity or are restricted due to other reason write 0.)
    1. Dressing yourself up                    :       ___________________________
    2. Walking around the house            :       ___________________________
    3. Climbing up stairs                       :       ___________________________
    4. Bathing and showering         :       ___________________________
    5. Gardening or doing household chores:    ___________________________
    6. Running or jogging                      :       ___________________________
    7. Doing strenuous sports                :       _
  1. In the past four weeks, while doing strenuous activities you had chest pain-
    1. Quite often
    2. Less often
    3. Much less often
    4. Not at all
  1. In the past four weeks, how many average times did you take nitroglycerine medication to relieve chest pain?  :        _____________________________________________
  1. What is your satisfaction level regarding your treatment?

______________________________

  1. How much does chest pain restrict you from enjoying your life?

____________________________

  1. To what degree do you find your lifestyle changed due to chest pain?

__________________________________

  1. Do you ever become afraid that you may have sudden heart attack and die?

_____________________

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