Cardiac Patient Support Group Survey

Survey Purpose:
We’re putting together a support group for people living with heart events, and we want it to really work for you. This survey is designed to gather essential information from cardiac patients to help shape a support group tailored to your needs. We aim to understand your preferences regarding meeting frequency, ideal time of day, and session length, as well as your current emotional and mental well-being. Your input will help us create a supportive, accessible, and meaningful space that feels comfortable, helpful, and worth your time.

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1. Full Name

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2. Age Range:

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3. Phone Number

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4. Email Address

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5. Preferred Contact Method

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6. Which heart event(s) have you experienced? (Check all that apply).

Heart attack

Bypass Surgery

Device Implant Surgery (Pacemaker, Defibrillator or Other)

Transplant surgery

Other

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7.
When did your most recent heart event occur?

Within the last 3 months

3-12 months ago

Over a year ago

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8. Are you facing recovery:

Alone

With a caregiver/partner

In a formal rehab program

With other support (please describe)

Other (please specify)

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9. Do you follow a specific recovery plan, health routine, or protocol?

Yes - Doctor Prescribed

Yes - My own routine

No structured plan right now

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10. Are you experiencing any of the following? Select all that apply.

Anxiety: is characterized by feelings of fear, worry, and uneasiness, sometimes accompanied by physical symptoms such as sweating, restlessness, muscle tension, rapid heartbeat, and increased blood pressure

Loneliness: is a feeling of sadness or distress about being alone or isolated. It occurs when a person perceives a gap between their desired social connections and their actual social relationships.

Depression: describes persistent feelings of sadness, emptiness, or hopelessness, and a loss of interest or pleasure in activities once enjoyed

Optimism: describes an attitude or mindset characterized by hope, confidence, and the expectation that future events will generally lead to positive, favorable, and desirable outcomes

Gregariousness: means being fond of the company of others and enjoying socializing.

Altruism: is a selfless concern for the well-being of others, involving actions intended to help others even at some cost or risk to oneself, without expecting reward or reciprocity

Seeking positive emotionality and warmth.

None of the above

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11. How would you like to attend support sessions

In person

By phone (conference call)

By Zoom or other video conference platform

By a hybrid method (combination of the methods listed above)

No preference

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12. What is the best time of day for the support session?

Morning

Afternoon

Evening

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13. What day of the week should the support session occur?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

No Preference

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14. How long do you think a support session should last?

30 minutes

1 hour

1.5 hours

2 hours

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15. How often should the support session occur?

Weekly

Biweekly

Monthly

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16. Would you value a group that includes spiritual or faith-based support?

Yes

Maybe / Open to it.

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17. Would you like to provide any additional information about your demographic background? (optional).

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18. What would you hope to get out of a support group?

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19. What else would have been useful for you to know to get you started?

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20. Would you like to be contacted with more information about joining our Cardiac Support Group?

Yes

Maybe if (please specify)

Cardiac Patient Support Group Survey

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* 1. Full Name

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* 2. Age Range:

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* 3. Phone Number

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* 4. Email Address

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* 5. Preferred Contact Method

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* 6. Which heart event(s) have you experienced? (Check all that apply).

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* 7. When did your most recent heart event occur?

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* 8. Are you facing recovery:

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* 9. Do you follow a specific recovery plan, health routine, or protocol?

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* 10. Are you experiencing any of the following? Select all that apply.

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* 11. How would you like to attend support sessions

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* 12. What is the best time of day for the support session?

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* 13. What day of the week should the support session occur?

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* 14. How long do you think a support session should last?

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* 15. How often should the support session occur?

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* 16. Would you value a group that includes spiritual or faith-based support?

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* 17. Would you like to provide any additional information about your demographic background? (optional).

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* 18. What would you hope to get out of a support group?

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* 19. What else would have been useful for you to know to get you started?

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* 20. Would you like to be contacted with more information about joining our Cardiac Support Group?

1. Full Name

2. Age Range:

3. Phone Number

4. Email Address

5. Preferred Contact Method

6. Which heart event(s) have you experienced? (Check all that apply).

7.
When did your most recent heart event occur?

8. Are you facing recovery:

9. Do you follow a specific recovery plan, health routine, or protocol?

10. Are you experiencing any of the following? Select all that apply.

11. How would you like to attend support sessions

12. What is the best time of day for the support session?

13. What day of the week should the support session occur?

14. How long do you think a support session should last?

15. How often should the support session occur?

16. Would you value a group that includes spiritual or faith-based support?

17. Would you like to provide any additional information about your demographic background? (optional).

18. What would you hope to get out of a support group?

19. What else would have been useful for you to know to get you started?

20. Would you like to be contacted with more information about joining our Cardiac Support Group?