10
s
:
ital number
NHS/Hosp
h:
Date of birt
lmonary e how pu tion determin every ques signed to er de sw is an re tionnai . Please es your This ques s your life st describ ct be fe af at ) th H R ion (P E NUMBE hypertens er the ON . g a tick ov perience. by placin ing with PH liv es your ex of e st describ perienc x that be recent ex ) in the bo d by my a tick ( Name:
, place item below For each
energy
flight of lk up one less When I wa not breath stairs I am public ent out in nfid co I am my PH ds despite places/crow PH does
ol not contr
0
1
2
3
4
5
0
1
2
3
4
5
my life
endent I am indep l I never fee
1
0
1
0
n like a burde
2 2
3 3
4 4
all energy at
flight lk up one When I wa athless am very bre of stairs I all in public at t en confid of my PH I am not use ca ds be places/crow my life controls ly lete PH comp
5
4
3
2
1
0
sted feel exhau
I have no
5
4
3
2
1
0
I always
5
4
3
2
1
0
t need to res I always day during the
5
4
3
2
1
0
d l exhauste I do not fee s of I have lot
1
0
ver athless ne Being bre rsations my conve interrupts t ed to res ne t no I do day during the
ays athless alw Being bre rsations my conve interrupts
5
4
3
2
frustrate I am very sness breathles
5
4
3
2
1
0
by frustrated I am not lessness my breath
5 5
ndent letely depe I am comp I always
burden feel like a
t e: SpoDat Mono
Total: Process
pulmonary
hypertens
ion asso
ciation
n Octo 54mmUK. Date of publicatio © 2013 PHA idetity Size for the le Minimum text legib to keep all
ber 2013
Copyright
/Y:0/K:0
/M:0 Process C:10
K:6 0/M:60/Y:0/ Process C:10 /K:0 M:100/Y:100 Process C:0/ /Y:80/K:0 /M:0 C:50 Process
V2.0
Mono
k
Blac Pantone:
5
294 Pantone:
032 Pantone: 368 Pantone:
