AFA Australia members questionnaire Survey

Thank you for taking the time to complete this questionnaire.

If you would be willing to share your suggestions and ideas with AFA, please contact: info@atrialfibrillation-au.org

For further information on Atrial Fibrillation, visit: http://www.atrialfibrillation-au.org/

1. Are you a

Are you a - Patient?

- Carer?

- Other (please specify)

2. Date of birth of AF patient

	MM		DD		YYYY
Please complete	Date of birth of AF patient Please complete Month	/	Day	/	Year

3. Gender of AF patient

Gender of AF patient - Male

- Female

4. Where are you located in Australia?

Where are you located in Australia?

5. Have you / the patient been diagnosed with any of the following?

Have you / the patient been diagnosed with any of the following? - Atrial Fibrillation

- Atrial Flutter

- Both

- Atrial Tachycardia

- Tachycardia

- Arrhythmia

- Syncope

- Other

- No diagnosis

6. If any, what symptoms do you / the patient experience?

If any, what symptoms do you / the patient experience? - Palpitations - Chest pains - Breathlessness	- Fatigue - Anxiety - Passing too much urine	- Sweating
- Other (please specify)

7. Are you / the patient currently seen by?

Are you / the patient currently seen by? - GP

- Cardiologist

- Arrhythmia nurse

- Heart rhythm specialist

- Other

8. Have you / the patient undergone any of the following tests?

Have you / the patient undergone any of the following tests? - 12-lead ECG - 24-hour ECG monitor - Echocardiogram	- Loop/event/memo recorder - Treadmill test - Blood test
- Other (please specify)

9. Please indicate the medications you / the patient are currently taking:

Please indicate the medications you / the patient are currently taking: - Amiodarone - Aspirin - Beta Blockers - Clopidogrel - Digoxin	- Diltiazem - Disopyramide - Dronedarone - Flecainide - Propafenone	- Sotalol - Verapamil - Warfarin
- Other (please specify)

10. Have you / the patient experienced a TIA or stroke?

Have you / the patient experienced a TIA or stroke? Yes

11. Do you have / is there a history of high blood pressure?

Do you have / is there a history of high blood pressure? Yes

12. Have you / the patient been diagnosed with heart failure?

Have you / the patient been diagnosed with heart failure? Yes

13. Have you / the patient undergone any of the following procedures?

Have you / the patient undergone any of the following procedures? - Cardioversion with drugs, (no. of times) - Electrical cardioversion, (no. of times) - Catheter ablation, (no. of times)	- Pacemaker and AV Node ablation - Mini maze
- Or had a cardiac device implanted? If yes, please give details.

14. Are you satisfied with your current treatment?

Are you satisfied with your current treatment? Yes	No
Please give further details/comments

AFA Australia members questionnaireExit this survey