NY classification

Appletree Medical Practice

Name

First

Last

Date

Address

Please tick one of the following:

I have no symptoms and no limitation on physical activity

Mild symptoms with slight limitation of physical activity but comfortable at rest

Moderate symptoms with marked limitation of physical activity but still comfortable at rest

Severe symptoms causing inability to perform physical activity without discomfort, symptoms at rest

If you are human, leave this field blank.

Heart Failure