What do you need this year to help with your afib?

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* 1. When it comes to your atrial fibrillation, what is the single biggest challenge you're facing? Please be specific, and provide details.

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* 2. Please rank the following afib-related topics in the order of your interest.

(You may drag and drop to re-order in your level of interest. 1 is highest interest. 7 is lowest interest.)

Causes & Risk Factors

Medications

Stroke Risk / Prevention

Catheter Ablation

Surgery

Left Atrial Appendage Closure

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* 3. What is the most important thing you hope to accomplish with your afib this year?

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* 4. Where are you located? (If you split your time among different locations, feel free to list them.)

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* 5. Which of the following best describes you?

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* 6. Which of the following best describes your age?

75+

65-74

55-64

45-54

35-44

25-34

Under 25

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* 7. Lastly, we will send notifications and updates about the 2018 Atrial Fibrillation Patient Conference via email. If you'd like to receive updates and more information about the patient conference and the most up to date afib news, please leave your name, email, and phone number below. Thank you so much!

Name

Email Address

Phone Number (Optional)