Chronic angina checklist

1. In the past month, how many times have you had angina?

None1-45-89 or more

2. Have you cut back or totally given up any activities or work because of your angina?

yesno

3. Do you ever have angina while:

restingworking around the house or in the yardin hot or cold weather
dressing or bathingfeeling stressedeating large meals
walking at an ordinary pacehaving sexsmoking cigarettes
walking uphill or quicklymoving heavy objectsother times
climbing stairs

4. How much has angina affected your quality of life?

12345 yesno

6. Is there anything else you would like to talk with your doctor about?

(check all that apply)