Share Your Story
Name
First Name
Last Name
Email
example@example.com
Phone
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Age
Marital Status
Spouse's Name (If Applicable)
First Name
Last Name
Do you have children?
Yes
No
If you have children, please provide their names and ages.
How long have you lived in the Richmond area?
How long have you been involved with the American Heart Association?
What are your favorite hobbies or pastimes?
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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?
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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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