"I am CardioSmart" Patient Contest Entry Form 2014

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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? Check all that apply.

Atrial Fibrillation

Congenital Heart Defect

Coronary Artery Disease

Heart Attack

Heart Failure

High Blood Pressure

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

Read and watch our Patient Stories to hear from last year’s winner, David Wang, and others managing heart disease: 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 are you able to 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. How did you learn about the “I am CardioSmart” contest?

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* 14. As a final step, please email a clear photo of yourself to cardiosmart@acc.org with the subject line “I am CardioSmart contest photo.”

If you are selected as a winner, this photo will appear on the CardioSmart Facebook page so that the CardioSmart community may select a grand-prize winner. (You are not required to have a Facebook account.)