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.

Thank you!
The Now What Team

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Your first name: *
Best email and phone number to reach you at: *
Your age: *
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? *
Are you from the Caribbean or of Caribbean descent? *
Were you …? *
What is your country of descent? *
Do you currently suffer from any of the following conditions?   *
Required
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? *
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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