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Screening for AF Survey - 2016
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1.
Please select your age bracket:
(Required.)
18-24
25-30
31-40
41-50
51-60
61-70
71-80
81+
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2.
Please indicate your gender:
(Required.)
Male
Female
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3.
Please select the country you reside in:
(Required.)
Australia
Canada
China
England
France
Germany
India
Indonesia
Ireland
Japan
New Zealand
Poland
Scotland
South America
Spain Africa
Sweden
Turkey
UK
USA
Wales
Other
Other – please state
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4.
Please specify which condition you have been diagnosed with:
(Required.)
Atrial fibrillation
Atrial flutter
No diagnosis
5.
Were you ever screened for AF (routine pulse check/ECG/EKG)?
Yes
No
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6.
Please share more about how your atrial fibrillation or flutter was detected. Did a screening program detect it, or would one have caught it more quickly?
(Required.)
7.
Do you have any thoughts about screening for atrial fibrillation or flutter and how we can make sure that people are screened and detected quickly?
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8.
Please state, as accurately as possible, the length of time between first being aware of symptoms (such as palpitations) to diagnosis:
(Required.)
9.
If you are still awaiting diagnosis, what do you think is delaying this?
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10.
What symptoms do you experience (please select all which apply):
(Required.)
Anxiety
Breathlessness
Chest pains
Excess sweating
Fatigue
Palpitations
Passing too much urine / frequent need to urinate
Syncope (fainting/loss of consciousness)
Light headed
N/A
Other (please specify)
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11.
Have you experienced a TIA or stroke?
(Required.)
Yes
No
