Heart Failure Annual Review Heart Failure Assessment As part of your annual review, we would like you to answer one quick question on your symptoms (if any). Name First Last Address Street Address Address Line 2 City Postal Code Phone OptionalDate of Birth Day Month Year Which of the following statements best describes your Heart Failure symptoms:. 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