Name & date of assessment
(1) CareGiver
Observes Orthopnea
(2) Patient
Reports Orthopnea
(3) Sleeps
with Pillows
(4) Sleeping
Sitting Up
(5) Sleeping
in Chair
(6) NEW Shortness
of Breath
(7) SOB
Climbing Stairs
(8) SOB Rising
from Chair
(9) SOB
Dressing
(10) SOB
Walking
(11) SOB
Talking
(12) SOB
Resting
(13) Reduced
Activity
(14) SOB
Increased
(15) Increased
Fatigue
(16) Legs or
Feet Swollen
(17) Foot
Swelling
(18) Leg
Swelling
(19) Swelling in
One or Both Legs
(20) Swelling
Warm to Touch
(21) Swelling
is Tender
(22) Swelling
has Redness
(23) Wounds
on Swollen Area
(24) Wet
Wound
(25) RX
for Diuretics
(26) Diuretic
Adherence
(27) Compression
Stockings RX
(28) Stockings
Adherence
