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Do not use this form for urgent medical help. If you think you may be having a heart attack, call 911, even if you are unsure. Do not drive yourself or delay help to complete this worksheet. Symptoms can be mild or come and go.
You can start with one question and skip the other fields.
01
Where do you feel it?
Point to the spot or describe the area. Does it move into your arm, jaw, back or elsewhere?
02
When did it start?
Suddenly or gradually? What were you doing? Has this happened before, and is this time different?
03
What does it feel like?
Pressure, tightness, burning, aching, stabbing or another feeling? Use your own words.
04
What is the pattern?
How long does each episode last? How often? Is it constant, coming and going, or changing?
05
What makes it better or worse?
Activity, meals, position or deep breaths? What have you tried, including medicine, and did it help?
06
How much does it affect you?
Rate discomfort from 0 (none) to 10 (worst imaginable), if helpful. What is harder to do or interrupts sleep?
07
What else happens with it?
Breathlessness, sweating, nausea, dizziness, weakness, a racing heart or another change?
Check your answers, then save or print.
HEART RESERVE · My appointment notes
Describe your symptoms
Only the answers you entered are included. A blank item does not mean “no” or “normal.” Review these notes with your care team.
To keep a PDF, choose “Save as PDF” or your device’s save/share option in the print preview. You can also download a text copy. Reopen your saved file to check it before closing this page.
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When not to wait
If you think you may be having a heart attack, call 911, even if you are unsure. Do not drive yourself or delay help to complete this worksheet. Symptoms can be mild or come and go.
Educational organizer, not a diagnosis, risk score or treatment plan. Your care team has not checked these notes. Keep your completed copy private and share it only with people you choose.
Lisa Zahakos, RPA-C · HEART RESERVE heartreserve.blog/worksheets/describe-symptoms
How to use these questions
You do not need medical words or perfect answers. Your clinician can help you explain what you feel. Use one sheet for one symptom, and attach extra notes if needed.
Start with: “I feel this, here. It started then. It lasts this long. This changes it. And this happens along with it.” Your description helps guide an evaluation; it does not establish the cause or rule out a heart problem.