My Heart Risk in Cancer Assessment

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What is Your Age?* This field is required.
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Have you ever been diagnosed with early stage breast cancer?* This field is required.
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Select any Medical Conditions that a Healthcare professional (e.g., Doctor, Nurse Practitioner) has diagnosed you with or told you that you have:* This field is required.
None
Ischemic Heart Disease (or Coronary Artery Disease, Coronary Heart Disease, Heart Attack, Heart Stent, Open Heart Bypass, Blockages in Heart Blood Vessel)
Diabetes (or Diabetes Mellitus or High Blood Sugar)
Hypertension (or High Blood Pressure)
Heart Failure
Atrial Fibrillation
Cerebrovascular Disease (or Stroke)
Chronic Obstructive Pulmonary Disease (or COPD, or Chronic Obstructive Lung Disease)
Peripheral Vascular (or Artery) Disease
Renal (or Chronic Kidney) Failure
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Signature Required* This field is required.By signing below, you consent to providing your contact and health information in order to complete the assessment, and you consent that you are aware that any information provided will only be used for these purposes. By signing below, you also acknowledge that this estimation assessment shares your risk level as a calculated probability based on your information, and that the information will not guarantee the development or absence of any health conditions. This is an educational tool, and the sole purpose is to provide information to consumers, not to provide any health diagnosis. Therefore, while we provide this calculated predictive information, we are not responsible for any future health conditions which may arise after taking this assessment. I attest that my electronic signature on this form is to have the same legally binding effect as my traditional handwritten signature. I am 18 years of age or older, and I am authorized to sign this form on my own behalf.
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Retrospective Review Consent FormWe provide this information for you to know an estimate of your heart risk in early breast cancer. In the future, we may want to look back on all of this work that we have produced to help you. When we look back at everything, we may want to capture summaries of all of the work. These summaries may involve combinations that have your information included in a way that is mixed with everyone else’s and cannot identify you at all. If we look back at this work in this way in the future, we may call this “retrospective research” review. We may present and publish some of the combined and mixed results from this work, in a way that could not identify you. This research review would focus on understanding the effects that cancer has on the heart and effectiveness of treatment and educational options, so that we can better tailor our services for the future. Through this research review, we may better understand the effects cancer has on the heart and determine which helpful educational and preventive methods are beneficial in building healthy heart habits. The research review committee will understand and respect the privacy of each and every individual. We would present and publish the combined and mixed information from our findings without disclosing your individual personal information in a way that could identify you. By signing below, you consent to your information being used as part of this future research review. In the future, you can write us if you ever change your mind and would like your information removed from the combined and mixed results in our research review. I attest that my electronic signature on this form is to have the same legally binding effect as my traditional handwritten signature. I am 18 years of age or older, and I am authorized to sign this form on my own behalf.
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In the next step, you will receive your estimated heart risk information based on your age, cancer, and medical problems, using a proven algorithm created and tested by cardiologists. The estimate is a probability and does not guarantee your risk. Let us know if you already have a cardiologist to help you, or if would like to have an appointment to visit with the cardiology clinicians at our affiliate My Heart Spark P.C. to learn more about minimizing your risk for heart problems going forward. The My Heart Spark P.C. team would be thrilled to see you if you need them.
Yes, I want to make an appointment at the affiliate My Heart Spark P.C. to learn how to minimize my risk for heart problems given my history of breast cancer. Please have someone email me with information for setting up an appointment at My Heart Spark P.C.
No, I do not want to make an appointment at My Heart Spark P.C. to learn how to minimize my risk for heart problems given my history of breast cancer. Please have someone email me to get my feedback, but I do not want an appointment.
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Since you have not been previously diagnosed with Early Stage Breast Cancer or not sure about your diagnosis, we have other resources to help you create an action plan for protecting your heart and preventing heart problems related to your specific cancer treatment. Click the link below to send us a message letting us know the type of cancer (including the stage), your cancer treatments and we will contact you with the correct forms pertaining to your specific situation.

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