Indicate the patient's medical record number.

Please provide the patient's date of birth

Please provide the patient's sex at birth

What is your ethnicity (Select all that apply) 0 = American Indian or Alaska Native

What is your ethnicity (Select all that apply) 1 = Asian

What is your ethnicity (Select all that apply) 2 = Black or African American

What is your ethnicity (Select all that apply) 3 = Hispanic or Latino

What is your ethnicity (Select all that apply) 4 = Native Hawaiian or Other Pacific Islander

What is your ethnicity (Select all that apply) 5 = White

What is your ethnicity (Select all that apply) 6 = other or 999=unknown (only fill out, if none of the above)

Please indicate the height of the patient

Indicate units of height

Please indicate the weight of the patient

Indicate units of weight

Have you ever been told by your doctor that you have atrial fibrillation?

Have you ever been told by your doctor that you've had a heart attack (this is sometimes called a myocardial infarction, or MI)?

Do you currently smoke, or have you smoked cigarettes or tobacco over the past year?

Do you drink more than one alcoholic drink a day?

Indicate whether the patient has a documented history of hypertension, diagnosed and treated with medication and/or diet and/or exercise

Have you ever been told by your doctor that you have diabetes?

Indicate whether the patient has a chronic lung disease

Indicate whether the patient has a diagnosis of renal dysfunction

Indicate whether an echocardiogram was performed to assess ejection fraction

If "1 = yes" to ECHOPERF, please state range of patient’s ejection fraction:

Please indicate diagnostic categories: 1 = Ischaemic

Please indicate diagnostic categories: 2 = Hypertensive

Please indicate diagnostic categories: 3 = Valvular

Please indicate diagnostic categories: 4 = Familial

Please indicate diagnostic categories: 5 = Peripartum

Please indicate diagnostic categories: 6 = Myocarditis/Inflammatory

Please indicate diagnostic categories: 7 = Infiltrative

Please indicate diagnostic categories: 8 = Stress/Takotsubo

Please indicate diagnostic categories: 9 = Chagas Disease

Please indicate diagnostic categories: 10 = Idiopathic/Other

Please indicate diagnostic categories: 999 = Unknown

Indicate whether the patient is currently being prescribed medication for heart failure

Indicate whether ACE inhibitors are currently prescribed for heart failure

Indicate whether Angiotensin Receptor II Blockers are currently prescribed for heart failure

Indicate whether an Angiotensin Receptor Blocker/Neprilysin Inhibitor combination is currently prescribed for heart failure

Indicate whether Beta Blockers are currently prescribed for heart failure

Indicate whether Calcium Channel Blockers are currently prescribed for heart failure

Indicate whether Digoxin is currently prescribed for heart failure

Indicate whether Diuretics are currently prescribed for heart failure

Indicate whether Hydralazine and Isosorbide Dinitrate are currently prescribed for heart failure

Indicate whether Ivabradine is currently prescribed for heart failure

Indicate whether Mineralocorticoid Receptor Antagonists are currently prescribed for heart failure

Indicate whether other medications are currently prescribed for heart failure

Did the patient receive a cardiac device to treat heart failure?

Indicate the device type

Indicate the date of DEVPROCEDURE

Did the patient undergo cardiac surgery?

Indicate the cardiac surgery type

Indicate the date of CARDSURG

Has cardiac rehabilitation been initiated?

Did the patient’s appointment or admission have any complications which were related to a device for Heart Failure including, but not exclusively: active bleeding requiring exploration and/or transfusion, abscess related to the device, minor infection (localized, treated with antibiotics and surgical drainage) related to the device, major infection (systemic, requiring device explant) related to the device, minor malfunction (requiring follow-up appointment/reprogramming), and/or major malfunction (requiring explant or revision)?

Indicate the date of COMPLDEVICE

Did the patient have a major healthcare-associated infection (requiring IV antibiotics and/or prolonged hospital stay – 14 days or more) during this admission?

Indicate the date of COMPLHOSP

Did the patient have a major adverse event related to Heart Failure medication during this admission, and/or as a cause of this admission?

Indicate the date of COMPLMED

How many times has the patient been hospitalised in the last 12 months due to heart failure?

How many hospital appointments has the patient had in the last 12 months due to heart failure?