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risk assessment survey

Please answer the questions below
1) Have you had a Sudden Cardiac Arrest?
       Yes    No    Not Sure

2) Has a blood relative died suddenly due to known or suspected heart disease?
       Yes    No    Not Sure

3) Have you had a heart attack(myocardial infarction)?
       Yes    No    Not Sure

4) Have you had coronary angioplasty(balloon) or stent, heart bypass surgery, or been diagnosed with coronary artery disease?
       Yes    No    Not Sure

5) Do you have or has your doctor ever said you have congestive heart failure? (typical symptoms include shortness of breath, ankle swelling and weight gain)
       Yes    No    Not Sure

6) Have you blacked out, almost blacked out, or lost consciousness(syncope) during the past year?
       Yes    No    Not Sure

7) Do you know your ejection fraction? (or EF - a measure of how well your heart pumps blood)
       Yes    No
If yes, please indicate what you know about your EF.
    My EF is less than 30%.
    My EF is 30%-40%.
    My EF is greater than 40%.
    I don't know the number, but my doctor indicated it is normal.
    I don't know the number, but my doctor indicated its abnormal.
Gender:
       Male    Female

Age:
       Under 40    40-50    51-60    61-70    71-80    Over 80

How did you hear about the SCA campaign?
         


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Heart Rhythm Foundation is an affiliate of the Heart Rhythm Society.
Address: 1400 K Street, Suite 500 Washington, DC 20005   Phone: 202.464.3404
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