Share Your Story
Street Address Line 2
State / Province
Postal / Zip Code
Spouse's Name (If Applicable)
Do you have children?
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?
What type of event did you experience?
Congenital Heart Defect
High Blood Pressure
Date of Event
Was a rescuer involved?
If so, what was the rescuer's name?
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.
Anything else you'd like us to know?
Please sign below to indicate that you have read and understood what is outlined in the PDF above.
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