• I have experienced shortness of breath daily for <3 months.
• I have experienced chest pain daily for <3 months.
• Walking is somewhat difficult for me.
• Climbing stairs is somewhat difficult for me.
• Exercising is not difficult for me.
• Standing is not difficult for me.
• Dressing and grooming is not difficult for me.
• Shopping is extremely difficult for me. I do not often rely on delivery services or loved ones for my shopping needs.
Continued next page
• Household chores are extremely difficult for me. I do often rely on outside services or loved ones to cook or clean for me.
• Performing my job is extremely difficult for me. I am able to work a full-time job with my symptoms.
• I have been diagnosed with the following health conditions: chronic obstructive pulmonary disease (COPD), other types of cardiomyopathy.
• I am currently treating my symptoms with:

  Over-the-counter medicines:

---

---

---

---

---

---

---

---

---

---

---

---

---

---