AF Association Patient Experience Survey

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1. Please indicate if you are a patient diagnosed with: (Required.)

AF (atrial fibrillation)

Atrial flutter

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2. Select your age bracket: (Required.)

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3. Please indicate your gender: (Required.)

Male

Female

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4. How was AF initially detected? (Required.)

By a pulse check

Experiencing palpitations?

Other symptoms

When having an unrelated procedure or treatment, the irregular heart rhythm was noticed

After suffering a TIA or stroke

Other – please indicate

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5. Please share, as accurately as possible, the length of time between first being aware of symptoms (such as palpitations) to diagnosis: (Required.)

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6. What symptoms do you experience (please tick all which apply): (Required.)

Anxiety

Breathlessness

Chest pains

Excess sweating

Fatigue

Palpitations

Passing too much urine / frequent need to urinate

Syncope (blackouts)

Light headed

N/A

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7. In which state & zip code do you receive treatment:

State:

ZIP:

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8. Who helps you manage your AF? (Required.)

Family Doctor

Cardiologist with specialism in heart rhythm disorders

General cardiologist

Internal Medicine physician

Other – please indicate

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9. Which of the following tests have you had? (Required.)

12 lead ECG

24-hr ECG monitor

Echocardiogram

Loop/event/ memo recorder

Treadmill test

Blood tests

Other – please indicate

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10. Please indicate the medications you are currently prescribed: (Required.)

No Medicine

Amiodarone

Apixaban

Aspirin

Beta-blocker

Clopidogrel

Dabigtran

Digoxin

Diltiazem

Disopyramide

Dronedarone

Flecainide

Propafenone

Rivaroxaban

Sotalol

Verapamil

Warfarin

Other – please list

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11. Please indicate any side effects you have experienced from any of the medications taken: (Required.)

Arrhythmia (other than AF)

Breathlessness

Depression

Fatigue

Hair loss

Lightheadedness

Nausea

Rash

Other – please indicate

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12. Have you experienced a TIA or stroke? (Required.)

Yes

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13. Do you have a history of high blood pressure? (Required.)

Yes

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14. Have you been diagnosed with Heart Failure? (Required.)

Yes

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15. Have you undergone any of the following procedures? Please select all that apply. (Required.)

None

Cardioversion with drugs

Electrical cardioversion

Catheter ablation

Pace maker and AV node ablation

Mini-maze

Surgical ablation

A cardiac device implanted

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16. The AF Association would welcome receiving your full case story on life with AF, from detection to treatment and life with AF. If you would consider sharing your case story please write your email address or contact details below and a member of the AF Association patient services team will contact you.

Please be reassured that your details will NOT be passed to any third party, and no information will be shared without your full permission.

Name:

Email Address:

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* 1. Please indicate if you are a patient diagnosed with: (Required.)

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* 2. Select your age bracket: (Required.)

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* 3. Please indicate your gender: (Required.)

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* 4. How was AF initially detected? (Required.)

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* 5. Please share, as accurately as possible, the length of time between first being aware of symptoms (such as palpitations) to diagnosis: (Required.)

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* 6. What symptoms do you experience (please tick all which apply): (Required.)

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* 7. In which state & zip code do you receive treatment:

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* 8. Who helps you manage your AF? (Required.)

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* 9. Which of the following tests have you had? (Required.)

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* 10. Please indicate the medications you are currently prescribed: (Required.)

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* 11. Please indicate any side effects you have experienced from any of the medications taken: (Required.)

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* 12. Have you experienced a TIA or stroke? (Required.)

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* 13. Do you have a history of high blood pressure? (Required.)

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* 14. Have you been diagnosed with Heart Failure? (Required.)

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* 15. Have you undergone any of the following procedures? Please select all that apply. (Required.)

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1. Please indicate if you are a patient diagnosed with: (Required.)

2. Select your age bracket: (Required.)

3. Please indicate your gender: (Required.)

4. How was AF initially detected? (Required.)

5. Please share, as accurately as possible, the length of time between first being aware of symptoms (such as palpitations) to diagnosis: (Required.)

6. What symptoms do you experience (please tick all which apply): (Required.)

7. In which state & zip code do you receive treatment:

8. Who helps you manage your AF? (Required.)

9. Which of the following tests have you had? (Required.)

10. Please indicate the medications you are currently prescribed: (Required.)

11. Please indicate any side effects you have experienced from any of the medications taken: (Required.)

12. Have you experienced a TIA or stroke? (Required.)

13. Do you have a history of high blood pressure? (Required.)

14. Have you been diagnosed with Heart Failure? (Required.)

15. Have you undergone any of the following procedures? Please select all that apply. (Required.)