Consider your full potential

The following questions are intended to help you reflect on how HAE has recently impacted you, so that you can communicate this during your next HAE checkup with your healthcare team. You may enter your responses directly into this form or print a blank assessment to write on it. Your information will not be collected in any way.

Every person’s experience with HAE is different, so don't hesitate to share any concerns you have with your healthcare provider. This will help them provide you with the care that best fits your needs.

NOTE: YOUR RESPONSES WILL NOT BE COLLECTED OR STORED.

Step 2. My Self-Assessment Questionnaire

1.

Even with your current treatment, how often are you still worried about your next unexpected attack? Please check one.

2.

Are you staying close to home in fear of another attack?

If yes, please describe.

3.

Has the fear of an impending HAE attack held you back from making plans with family and friends?

Please describe.

4.

Is the fear of an unexpected HAE attack holding you back from taking on educational or professional opportunities?

Please describe.

5.

What other ways does HAE currently impact the way you live your life between attacks?

Please describe.

6.

Now that HAE and its impact on your life are fresh in your mind, do you believe life could be better?

Please describe.

Take a PDF of your responses to share with your HAE healthcare team. Don’t be afraid to ask for resources and support that will help you deal with the emotional concerns you have identified through this reflection exercise.

In order to save and/or share the summary PDF it is recommended to use the Safari browser.

Please complete the form.


MY CARE PLAN

HAE can affect each person differently. It’s important to work with your healthcare team to create a care plan that is right for you.

My Self-Assessment Questionnaire

1.

Even with your current treatment, how often are you still worried about your next unexpected attack? Please check one.

2.

Are you staying close to home in fear of another attack?

If yes, please describe.

3.

Has the fear of an impending HAE attack held you back from making plans with family and friends?

Please describe.

4.

Is the fear of an unexpected HAE attack holding you back from taking on educational or professional opportunities?

Please describe.

5.

What other ways does HAE currently impact the way you live your life between attacks?

Please describe.

6.

Now that HAE and its impact on your life are fresh in your mind, do you believe life could be better?

Please describe.