ACP Heart Failure Survey
1.
Gender
Male
Female
2.
Age
Under 18
18-34
35-54
55+
3.
How long have you been diagnosed with heart failure?
Less than one month
1-6 months
7 months - 1 year
1-5 years
6+ years
4.
How did you learn about the Heart Failure Guide?
Health Plan
Hospital
Outpatient Clinic
Employer
Other (please specify)
5.
How would you rate overall satisfaction with the Heart Failure Guide?
Very satisfied
Satisfied
Neutral
Dissatisfied
Very dissatisfied
6.
I have a better understanding of my condition as a result of reading the Heart Failure Guide.
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
7.
I feel more confident about managing my condition as a result of reading the Heart Failure Guide
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
8.
I will use ideas from the Heart Failure Guide to help improve my health.
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
9.
In what ways has the Heart Failure Guide helped you manage your condition?
Understanding heart failure
Monitoring heart failure
Healthier eating/dieting
Getting more exercise
Understanding the risk factors
Understanding and using your medication
Feeling better about your condition
10.
What changes or improvements would you make to the Heart Failure Guide?
11.
Do you have any additional comments?