Cardiac Support Treatment Selection Survey
Help us understand your needs and preferences for cardiac support treatments. Your input will guide treatment selection and care planning.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
Gender
*
Male
Female
Other
Do you have any of the following existing cardiac conditions?
*
Heart Failure
Arrhythmia
Coronary Artery Disease
Previous Heart Attack
Hypertension
Other
Please rate the severity of your current symptoms:
*
Rows
None
Mild
Moderate
Severe
Shortness of breath
1
2
3
4
Chest pain
5
6
7
8
Fatigue
9
10
11
12
Swelling in legs/feet
13
14
15
16
Which cardiac support treatment options are you interested in learning more about or considering?
*
Medication Management
Implantable Devices (e.g., pacemaker, defibrillator)
Mechanical Circulatory Support (e.g., LVAD)
Heart Transplant
Lifestyle Modification
Other
How important are the following factors in your treatment selection?
*
Rows
Not important
Somewhat important
Very important
Effectiveness
17
18
19
Risk of complications
20
21
22
Recovery time
23
24
25
Impact on lifestyle
26
27
28
Cost
29
30
31
How confident do you feel about making decisions regarding your cardiac treatment options?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
Please share any specific questions, concerns, or preferences regarding your cardiac support treatment.
Submit Survey
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