Are you evaluating a patient with end-stage heart disease?

Age of the patient


Unexplained weight loss in the past 6 months (enter 0 if none)

Has the patient experienced a decline in functional status with need for assistance in daily ADL?

Does the patient require high daily doses of a loop diuretic such as furosemide?

Resting heart rate

beats per minute

Does the patient have a persistent S3 gallop?

Has the patient had a ventricular fibrillation/tachycardia arrest ?

Does the patient have an implantable cardiac defibrillator?

Serum creatinine

Serum sodium

Serum albumin


Does the patient have a documented site of bleeding?

Worst NYHA status in the past year


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