Are you or a loved one

at risk of heart
valve disease?

Fill out the questionnaire

It’s not always easy to tell if you or a loved one has heart valve disease. There aren’t always symptoms and if there are, they can be subtle.

Take a few minutes to answer the questions below and get a personalized discussion guide to have a conversation with your doctor about heart valve disease and ask for an echocardiogram.

Hi, who's this for?

1

Are you taking this for you or someone else?

Please select an option.

Age

2

How old are you?

Please select an option.

Family history

3

Does your family have a history of heart conditions?

Please select an option.

Murmur

4

Have you been checked for an abnormal heart murmur?

Please select an option.

Echocardiogram

5

Have you ever had an echocardiogram, a simple heart ultrasound?

Please select an option.

Activity level

6

Compared to 6 months ago, or even a year, do you still do daily activities and hobbies you’ve always enjoyed? (long walks, golf, cooking, time with family/friends, going to the store, etc.)

Please select an option.

Signs/Symptoms

7

Which of the below sound like you?

Please select an option.

Progress

1 of 7 questions

Hi, who's this for?

1

Are you taking this for you or someone else?

Please select an option.

Age

2

How old are they?

Please select an option.

Family history

3

Do they have a family history of heart conditions?

Please select an option.

Murmur

4

Have they been checked for an abnormal heart murmur?

Please select an option.

Echocardiogram

5

Have they ever had an echocardiogram, a simple heart ultrasound?

Please select an option.

Activity level

6

Compared to 6 months ago, or even a year, does it seem like they're avoiding their daily activities and hobbies they’ve always enjoyed? (long walks, golf, cooking, time with family/friends, going to the store, etc.)

Please select an option.

Signs/Symptoms

7

Which of the below sound like them?

Please select an option.

Progress

1 of 7 questions


Already signed up? Manage your subscription
We’ve received your information. You should get a confirmation email shortly. Be sure to check your junk mail folder.