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Have a heart-to-heart

with your cardiologist

If you’ve been diagnosed with supraventricular tachycardia (SVT), complete your SVT Impact Profile below to discuss with your cardiologist. If you haven’t seen a cardiologist yet, talk with your healthcare provider about seeing one.

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Answer the following 12 questions about the impact SVT has on your life—both during and between episodes.

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Once you’ve answered the questions, bring your personalized SVT Impact Profile with you to your next visit.

Your SVT Impact Profile is below.

Be sure to bring this with you to your next appointment, so you can have a heart-to-heart discussion with your doctor. You can download to print or save this file to your desktop. If you’re using a mobile device, click to download and save to your files.
SVT Heart to Heart logo
My SVT Impact Profile
Episode impact
The most recent episode was:
The most recent episode that was very concerning:
Thoughts about experiencing a possible future episode:
The aspects of the episode that were concerning:
After the episode, I felt:
Changes in SVT episode frequency, intensity, or duration since last visit:
Symptom assessment
During the episode, my symptoms included:
Emergency care
Emergency department or urgent care experience:
Lifestyle and relationship impact
SVT impact on quality of life:
Modified or restricted activities:
SVT impact on relationships:
Treatment satisfaction
Level of satisfaction with SVT medication:
Current medications
Notes Add any additional notes to discuss with your healthcare provider.
Appointment reminder
Date:
Time:

How long ago was your most recent episode?

  • Within the last month
  • 1-3 months ago
  • 3-6 months ago
  • 6-12 months ago
  • 1-2 years ago
  • More than 2 years ago

Think about your last SVT episode that was very concerning to you.

How long ago was that episode?

  • Within the last month
  • 1-3 months ago
  • 3-6 months ago
  • 6-12 months ago
  • 1-2 years ago
  • More than 2 years ago

Think about your last SVT episode that was very concerning to you.

What aspects of the episode were concerning to you?

  • Symptoms
  • Length
  • How much it interfered with something I was doing
  • Going to the emergency department
  • Figuring out what to do in the moment

Think about your last SVT episode that was very concerning to you.

During the episode, my symptoms included:

  • Palpitations
  • Anxiety or panic
  • Chest pressure or pain
  • Shortness of breath
  • Sudden exhaustion
  • Fainting or passing out
  • Dizziness or lightheadedness
  • Sweating
  • Other

Think about your last SVT episode that was very concerning to you.

After the episode, I felt:

  • Physically exhausted
  • Emotionally drained
  • Anxious about when it would happen again
  • Side effects from medication
  • I recovered without any problems
On a scale from 0 to 10, how much do you worry today about the possibility of experiencing an SVT episode in the future?
Scale 1 to 10
On a scale from 0 to 10, how much impact does SVT have on your quality of life?
Scale 1 to 10
Because of SVT, I’ve had to modify or restrict certain activities, such as:
  • Exercising
  • Sleeping
  • Traveling/driving
  • Social gatherings
  • Shopping
  • Household chores like cooking or cleaning
  • Performing my job/going to class
  • I haven’t had to modify or restrict any activities
  • Making certain future plans
  • Other
Because of SVT, I have had to modify relationships with people in my life, including:
  • My significant other
  • My children
  • My friends
  • My colleagues
  • I haven’t had to modify any relationships
If you’ve gone to an emergency department or urgent care for any SVT episode within the past 2 years, how was your experience?
  • I felt confident that I was getting the right care in the right moment
  • I felt like my symptoms were downplayed or dismissed
  • I was given a treatment that led to unpleasant side effects
  • It was time-consuming
  • It was expensive
  • I have not gone to an emergency department or urgent care for an SVT episode in the past 2 years
  • I chose not to go to an emergency department or urgent care even though I was having an episode
If you take a pill to try to stop SVT episodes when they occur, how satisfied are you with that treatment?
  • Satisfied, because it stops my episodes without side effects
  • Dissatisfied, because it takes too long to work and/or it doesn’t stop my episodes
  • Somewhat satisfied, because it stops my episodes but I experience side effects
  • I haven’t been prescribed a pill for SVT
Have your SVT episodes gotten worse in frequency, intensity, or duration since your last visit?
  • Yes
  • No
  • I’m not sure
Current medications
Notes Add any additional notes to discuss with your healthcare provider.
Appointment reminder
Date:
Time: