"I am CardioSmart" Patient Contest Entry Form

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* 1. Contest Entry Form

Name:

Address:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

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* 2. Gender

Male

Female

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* 3. Facebook Site (optional)

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* 4. Twitter Username (optional)

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* 5. Accessibility needs? I travel with a:

Service Animal

Personal Aide

Wheelchair/Scooter

Other (please specify)

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* 6. What heart condition(s) do you have?

Atrial Fibrillation

Congenital Heart Defect

Coronary Artery Disease

Heart Attack

Heart Failure

High Blood Pressure

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* 7. Tell us your CardioSmart story (1,000 words max.) We want to hear how you have tackled heart disease and now live life to the fullest while managing a heart condition.

For inspiration, watch and read our Patient Stories to learn about other patients' struggles and accomplishments on the road to a healthier heart: https://www.cardiosmart.org/Connect/Patient-Stories

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* 8. How do you work with your doctors and care team to stay on top of your heart condition? (100 words max.)

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* 9. What lifestyle changes did you make to improve your heart health? (100 words max.)

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* 10. What challenges do you face? How have you overcome them? (100 words max.)

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* 11. Who is your support system? (100 words max.)

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* 12. Do you have a personal motto? What inspires you? (100 words max.)

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* 13. To complete your entry, please send your full name and a recent photograph of yourself to cardiosmart@acc.org with the subject line: I am CardioSmart.

If you are selected as a winner, this photo and a blurb from your success story will appear as a post on the CardioSmart Facebook page in order to select the grand-prize recipient. (You are not required to have a Facebook account.)