Heart Sufficiency Questionnaire
Name, First Name:
Date of Birth: Date:
1. DO YOU WAKE UP AT NIGHT?
(Bedtime is assumed to be between 10 PM & 11 PM)
a) Yes, between 1:00 & 2:00 AM = 6 points _____
b) Yes, between 3:00 & 4:00 AM = 4 points _____
c) Yes, between 5:00 & 6:00 AM = 2 points _____
d) Yes, constantly with sleeping phases in between = 8 points _____
Score _______
2. ARE YOU ABLE TO GO RIGHT BACK TO SLEEP?
a) Yes, after urinating = 0 points _____
b) No, I stay awake for a long time and read lying down = 2 points _____
c) I am restless and have to get up = 4 points _____
d) I need to walk around for a long time
(more than 15 minutes) = 6 points _____
e) It take me hours to fall back to sleep = 8 points _____
Score _______
3. DO YOU HAVE NIGHT SWEATS?
a) Yes, I have had them for more than 6 months = 8 points _____
b) Yes, recently on a daily basis = 6 points _____
c) Every now and then = 2 points _____
d) Yes, periodically when I have a cold = 0 points _____
(During the beginning of menopause count only 1/2 points)
Score _______
4. HOW WOULD YOU DESCRIBE YOUR NIGHT SWEATS?
a) Whole body = 8 points _____
b) Face, neck and chest = 6 points _____
c) Only on neck and chest = 4 points _____
d) Only on the neck = 2 points _____
Score _______
5. DO YOU WAKE UP WITH A POUNDING HEART?
a) Yes, it pounds for many hours regardless of what I do = 8 points _____
b) Yes, my chest is vibrating or it is pounding up to my neck = 6 points _____
c) Yes, the pounding will not go away until I get up = 4 points _____
d) Yes, but I can stay lying down
and it will stop soon afterwards = 2 points _____
Score _______
6. DO YOU WAKE WITH PRESSURE / PAIN IN YOUR CHEST?
a) Yes, the pressure lasts for hours = 8 points _____
b) Yes, the pressure will only go away after walking
around for a long time = 6 points _____
c) Yes, the pressure goes away directly after getting up = 4 points _____
d) Yes, the pressure goes way right after sitting up = 2 points _____
Score _______
7. DO YOU WAKE UP WITH A PULLING TOWARDS YOUR LEFT ARM,
OR IN YOUR LEFT LOWER JAW, OR
DOES YOUR LEFT SHOULDER SEEM TO HURT WITHOUT GOOD REASON?
a) Yes, the pain stays for hours = 8 points _____
b) Yes, often = 6 points _____
c) Yes, after getting up it gets better = 4 points _____
d) Yes, it gets better after sitting up = 2 points _____
Score _______
8. DO YOU AWAKE AT NIGHT APPARENTLY FOR NO REASON,
AND ARE WIDE AWAKE WITH A VERY CLEAR MIND, AND
YOU CANNOT STOP THINKING?
YOU COULD EVEN DO WORK OR WRITE POETRY?
a) Yes, regularly, I thought this was normal for me. = 8 points _____
b) Yes, I am so wide awake that I cannot go back to sleep = 6 points _____
c) Now & then, I think my thoughts are waking me up = 4 points _____
d) Occasionally, I then read or do something = 2 points _____
Score _______
9. DO YOU HAVE SHORTNESS OF BREATH?
a) Yes, during physical activity = 2 points _____
b) Yes, now and then at night = 4 points _____
c) Yes, regularly after lying down for a long time = 8 points _____
d) Only during strenuous sports = 0 points _____
Score _______
10. CAN YOU SLEEP LYING ON YOUR LEFT SIDE?
a) No, lying on my left side I experience heart trouble,
(i.e. shortness of breath or palpitations) = 8 points _____
b) I wake as soon as I lie on my left side = 6 points _____
c) I do not like to lie on my left side = 4 points _____
d) I can lie on either sides, and may change often = 0 points _____
Score _______
11. ARE YOU COUGHING CONSTANTLY?
a) Only when I have a cold = 0 points _____
b) Yes, for a long time and I do not know why = 2 points _____
c) Yes, when lying down or after lying down = 8 points _____
d) Yes, after lying down for a long time = 6 points _____
Score _______
Sum of the points of questions 1 to 11:
The Results
Group 1
Every one has the odd bad or sleepless night from time to time if our daily routine is strenuous.
Group 2
You are at risk from developing heart insufficiency. I would recommend that you should have the initial assessment.
Group 3
We recommend that you take your health seriously. There is a possibility that a preliminary stage of heart insufficiency or coronary artery disease is underlying. You should seek professional help.
Group 4
It is time concern yourself with your health! It is very probably that you have a preliminary stage of heart insufficiency. Please seek professional help.
Group 5
This is the highest risk category. Assumption of a preliminary stage of heart insufficiency. An appointment with your physician is a must. I strongly recommend that you seek an urgent appointment for a heart check up.
Do not wait any longer!
For more information see Dr. Hain’s translated article here:
https://oirf.com/2005/12/06/innovations-of-a-new-gentle-and-holistic-cardiology/
A translated article for Affiliates
From THE BRIDGE Newsletter of OIRF
Published December 8, 2005
© Copyright January 2004, Dr. Peter Hain
