List of questions in the Minnesota Living with Heart Failure Questionnaire
| The following questions ask how much your heart failure (heart condition) affected your life during the past month (4 weeks). After each question, circle the 0, 1, 2, 3, 4 or 5 to show how much your life was affected | |
| If a question does not apply to you, circle the 0 after that question. Did your heart failure prevent you from living as you wanted during the past month (4 weeks) by | |
| - No (0) Very Little (1) Very Much(5) | |
| 1. Causing swelling in your ankles or legs? | 0 1 2 3 4 5 |
| 2. Making you sit or lie down to rest during the day? | 0 1 2 3 4 5 |
| 3. Making your walking about or climbing stairs difficult? | 0 1 2 3 4 5 |
| 4. Making your working around the house or yard difficult? | 0 1 2 3 4 5 |
| 5. Making your going places away from home difficult? | 0 1 2 3 4 5 |
| 6. Making your sleeping well at night difficult? | 0 1 2 3 4 5 |
| 7. Making your relating to or doing things with your friends or family difficult? | 0 1 2 3 4 5 |
| 8. Making your working to earn a living difficult? | 0 1 2 3 4 5 |
| 9. Making your recreational pastimes, sports or hobbies difficult? | 0 1 2 3 4 5 |
| 10. Making your sexual activities difficult? | 0 1 2 3 4 5 |
| 11. Making you eat less of the foods you like? | 0 1 2 3 4 5 |
| 12. Making you short of breath? | 0 1 2 3 4 5 |
| 13. Making you tired, fatigued or low on energy? | 0 1 2 3 4 5 |
| 14. Making you stay in a hospital? | 0 1 2 3 4 5 |
| 15. Costing you money for medical care? | 0 1 2 3 4 5 |
| 16. Giving you side effects from treatments? | 0 1 2 3 4 5 |
| 17. Making you feel you are a burden to your family or friends? | 0 1 2 3 4 5 |
| 18. Making you feel a loss of self-control in your life? | 0 1 2 3 4 5 |
| 19. Making you worry? | 0 1 2 3 4 5 |
| 20. Making it difficult for you to concentrate or remember things? | 0 1 2 3 4 5 |
| 21. Making you feel depressed? | 0 1 2 3 4 5 |