Temp - Form Test Page - Heart Valve Insights

1Your Info

2About Your Valve

3Additional Questions

4Confirmation

Progress:
0%
What is your name?*
First Last
What is your email address?*
Enter Email Confirm Email
What do you enjoy doing? Tell us about yourself:*
Example: I was very anxious the time leading up to my aortic valve surgery. There is some much information out there that I wasn’t sure about which choice was best for me. I had a great support group that helped me along the way.

Progress:
20%
Tell Us About Your First Valve Replacement

Please fill out form below.
When did you learn you had a leaky/stenotic aortic valve?*
How did you feel before getting your valve replaced?*
Example: I was very anxious the time leading up to my aortic valve surgery. There is some much information out there that I wasn’t sure about which choice was best for me. I had a great support group that helped me along the way.
When did you get your first aortic valve replacement surgery?*
What type of surgery did you have?*
What type of valve did you get?*

Progress:
50%
How has your life improved after your first aortic valve replacement surgery?*
Example: My life has greatly improved since my first aortic valve replacement surgery! I am two years out and am back to running and living my normal life.
What are your biggest challenges after your first aortic valve replacement surgery?*
Example: My biggest challenge was learning how to keep my INR levels in range. It took some time after the surgery to get used to this. I found that a consistent diet has helped me keep my levels stable and I am able to exercise and continue to do the things I enjoy!
Are you planning to have another aortic valve replacement surgery?*
- Yes
- No
- Not Sure
If yes, how do you feel about having another aortic valve replacement surgery?*
Example: I am very anxious to go through the process again. I continue to have a great support group and want to make sure I am making the best decision to avoid re-operations in the future.
Please explain why you are not sure.*
Have you already had another aortic valve replacement surgery?*
- Yes
- No
If yes, how many years after your first aortic valve replacement did you get your second surgery?*
How did you feel BEFORE your second aortic valve surgery?*
What type of valve did you get for your second operation?*
How did you feel AFTER your second aortic valve surgery?*

Progress:
80%
What was your biggest learning and advice for someone planning for an aortic valve replacement surgery?*
Example: Trust in your cardiologist and surgeons! Waiting is the worst part so try not to worry. Sending thoughts your way!
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Please include your phone number so that we can contact you with questions.
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Please confirm you have read and agree to our privacy policy.*
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Tell Us About Your First Valve Replacement