Survey

Please answer all questions...
  3. Thank you, the following questions need only be completed by individuals diagnosed with Atrial Fibrillation (AF), suspected of having AF or are be completed on behalf of someone with Atrial Fibrillation.
  6. The following questions are in regard of the care and treatment of the person diagnosed with or suspected of having Atrial Fibrillation
  8. 5) Does the patient have a definite diagnosis? What is it (please tick all boxes that apply)
    Atrial Fibrillation
    Atrial Flutter
    Both
    Atrial Tachycardia
    Tachycardia
    Arrhythmia
    No
  9. 6) What symptoms does the patient experience?
    Palpitations
    Chest Pain
    Breathlessness
    Fatigue
    Anxiety
    Passing too much urine
    Sweating
    Other (please list below)
  10. 7) Is the AF patient seen by:
    GP
    Cardiologist
    Arrhythmia Nurse
    Heart Rhythm Specialist?
    Other (please list below)
  11. 8) Has the AF patient had any of the following tests (tick all that apply):
    12 lead ECG
    24 hour ECG monitor
    Echocardiogram
    Loop/Event/Memo Recorder
    Treadmill Test
    Blood test
    Other (please list below)
  12. 9) Please list the medications the AF patient is currently taking:
    Warfarin
    Aspirin
    Clopidogrel
    Amiodarone
    Dronedarone
    Flecainide
    Propafenone
    Sotalol
    Disopyramide
    Digoxin
    Verapamil
    Diltiazem
    others (please list below)
  13. 10) Has the AF patient experienced a TIA or stroke?
    Yes
    No
  14. 11) Does the patient have a history of high blood pressure (hypertension)?
    Yes
    No
  15. 12) Has the AF patient been diagnosed with Heart Failure?
    Yes
    No
  16. 13) Has the AF patient undergone any of the following procedures?
    Cardioversion with drugs
    number of times:
    Electrical cardioversion
    number of times:
    Catheter Ablation
    number of times:
    Pacemaker and AV Node ablation
    Mini Maze
    Had a cardiac device implanted? If yes, please give details:
  17. 14) Are you satisfied with your current treatment?
    Yes
    No
    Please explain further:

Please email: info@atrialfibrillation.org.uk if you have any queries or are unable to find information on any topic that you have been searching for