Survivor Questionnaire

Address

What type of event did you experience?

Congenital Heart Defect Stroke Heart Attack Cardiac Arrest Prevention/Lifestyle Change High Blood Pressure
Date of Event
Was a rescuer involved?

Yes No
If so, what was the rescuer's name?

First Name Last Name
Rescuer's Email
example@example.com
Rescuer's Phone

Area Code Phone Number
What is your current medical status?
Were you treated at a local hospital? If so, which hospital were you treated at?

For the remainder of this survey, please provide as much detail as you are comfortable providing.
How have heart disease and/or stroke touched your life?
If you experienced an acute, life-changing event due to a heart attack or stroke, please describe the circumstances and event in detail.
When you think about your event, how do you feel?
What, if any, treatments or surgical procedures did you receive and when?
If you were to pass along words of wisdom to those affected by heart disease or stroke, what would you say?
What is your most recent accomplishment or milestone? This does not have to be related to your event.
Please upload a photo of yourself we can share with your story.

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Anything else you'd like us to know?

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