Now What Research Survey
Hello and thanks for your interest in participating in our research project about your experiences with a heart condition. Please fill out the following questions, which should take about 5 minutes of your time. Someone from the team at Now What will be in touch shortly if you qualify.
The Now What Team
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Your first name:
Best email and phone number to reach you at:
The city and state you currently live in:
We are interested in ensuring that we include the views and opinions of people of all different ethnic backgrounds in our study. Which of the following best describes your ethnicity?
Black (Not African-American)
Hispanic or Latino
Are you from the Caribbean or of Caribbean descent?
Were you …?
Born outside the United States
Born in the United States, 1st Generation
Born in the United States, 2nd Generation
Born in the United States, 3rd Generation or more
What is your country of descent?
Antigua & Barbuda
British Virgin Islands
Trinidad & Tobago
Do you currently suffer from any of the following conditions?
Biceps Tendon Rupture
AFib (i.e., Atrial fibrillation)
Swelling of the legs and ankles (i.e., Edema)
Shortness of breath
Abnormal heart beat
Do you have a heart condition, heart disease, or heart failure? If so, please tell us about your condition. Do you have a diagnosis from a doctor? If so, tell us about that.
Please tell us about any other health conditions you're living with and/or see a doctor about.
Have you had a family member who’s passed away from a heart condition? If so, who?
Which of the following best describes your annual household income?
$45K to less than $60K
$60K to less than $75K
$75K to less than $100K
$100K to less than $150K
$150K OR MORE
Do you know anyone else that you think may qualify for this research? Friends, family members, neighbors, etc. If so, we'd like to know!
Do you have anyone in your support community that may be interested in participating in the support/caregiver version of our research? If so, we'd like to know!
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