Chronic Angina Checklist

It's important to help your cardiologist get a fuller picture of how angina affects you.

Before every cardiology appointment, complete this Chronic Angina Checklist and share it with your doctor.

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

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

If so, what?

3.Do you ever have angina while:

Check all that apply

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

not at all

a little


a lot

very much

5.Has angina affected your family life?

If so, how?

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

Check all that apply

Send the checklist to yourself via email. Once your email has been sent, will not save your email address.

*If you have angina that does not go away with rest or nitroglycerin, get emergency medical help right away.

If you still have angina even though you are getting treatment, talk with your doctor about your options.

The information on this website does not take the place of talking with your cardiologist or healthcare professional.

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