• Verify your information

    Let’s begin by verifying your information to help ensure your answers are linked securely to your health record.
    • Step 1: Personal Information 
    • Date of Birth*
       - -
    • Step 2: Patient Identification 

    • If you have the Personal Access Code from your CareFirst letter, you can enter it below.

    • Step 3: Additional Contact Details  
    • Format: (000) 000-0000.
    • Opt-in to communication by phone
    • Opt-in to communication by email

    • Note: Providing your email or phone number is optional, but it may help us confirm your identity and share program opportunities with you.

  • Your Heart History

  • Select from the following list, any heart conditions you've been diagnosed with either recently or in the past. If none apply, choose "No known heart condition."

  • Which heart conditions apply to you? (Select all that apply)
  • Do you have a blood pressure cuff at home, and do you feel comfortable using it?
  • In the past 2 months, have you felt your heart racing, fluttering, or beating irregularly?
  • When you walk, do you get leg pain or cramping that goes away when you rest?
  • Do you have a scale at home, and can you check your weight most days?
  • In the last 6 months, have you had worse shortness of breath, swelling, or lower activity that needed extra water pills (diuretics)?
  • In the past 2 months, have you had chest pressure, pain, or tightness with activity that eases with rest?

  • Chronic Condition (Non-Cardiac) History

    Other Ongoing Health Conditions

  • Select any other chronic conditions you have that are not related to your cardiovascular health. If none apply, choose "No known chronic health condition."

  • Do any of these apply to you? (Select all that apply)

  • Your Medications

  • We'll show medicine types below. For each one, confirm if you're taking it now. You can also add others at the end.

  • Which of these medicine types are you taking now? (Select all that apply)

  • A few final questions

  • Right now, is it hard to afford food, housing, transportation, or medications?
  • In the past week, did you miss 2 or more doses of any medicine?
  • Day to day, do you feel comfortable managing your health, like medicines, appointments, eating, and symptoms?
  • Which of the following best describes your relationship with a cardiologist?
  • Author of submission
  • Should be Empty: