Zap•Life
ICD Recipient - Submission Form
Contributer's Name:

(TYPE OVER/REPLACE)
Birthday:
Mo Day Year
Age
Address to ship finished book:
Street
Apt/Box
City
State ZIP/Post Country
E-Mail:
Day Phone:
Night Phone:
Privacy Statement:
We would love to publish the full name of every respondent, and how others may contact you... but we want that to be your choice. Do so, by selecting the level of privacy/revelation you choose:

Use Full Name Address/Email/Phone
Use Name/EMail--Not Address/Phone
Use Full Name/State
Use Only First Name/State

Heart Conditions
Check Conditions which apply to you
Angina
Anuerism
Atrial Fibrillation
Bacterial/Viral Damage
Bradychardia
Cardiomyopathy
Congenital Disorder
Congestive Heart Failure
Myocardial Infarction
Sudden Cardiac Death
Valve Disorder
Ventricular Fibrillation
Ventricular Tachycardia
Other:
Your ICD made by:


Current ICD's is your..


Your ICD &/or Pacemaker Device(s) are:


Do you remember having an EP
study before your ICD Implant?
Yes No

First ICD Implant (Month/Year)

Last ICD Implant:
Provide a short history of your cardiac problems
Please include dates
Cardiac Medications:
Check all prescribed for you now
Adalat
Aldactone
Altace
Amiodarone
Aspirin
Atromid-s
Betaloc
Blocadren
Capoten
Cardilate
Cardioquin
Cardizem
Cardura
Colestid
Cordorone		 Corgard
Coumadin
Dyazide
Hygroton
Imdur
Inderal
Ismo
Isoptin
Lanoxin
Lasix
Lescol
Lidocaine
Lopid
Lopressor
Lotensin		 Mevacor
Mexitil
Minipress
Monitan
Monoket
Monopril
Nifedipine
Nitro
Norvasc
Paxil
Plendil
Pravachol
Procainamide
Procardia
Questran		 Quinidex
Quinidine
Renedil
Rythmol
Sotacor
Sotalol
Tambocor
Tonocar
Trasicorv
Vasotec
Verapamil
Viskin
Xanax
Zaroxolyn
Zocor
Other:

Describe in detail any reactions/problems experienced from
specific drugs - either those taking now or those in the past.
Some people who have experienced heart trouble report memory problems.
Others taking various cardiac medicines report the same. Have you?
1=No New Problems - - - - - - - - - - 10=Severe Memory Problems
1 2 3 4 5 6 7 8 9 10
If you have gone through a Cardiac Rehabilitation Program, how much
of an impact has that program had on your quality of life and survival?
1=No Value - - - - - - - - - - - - - 10=Extremely Important
1 2 3 4 5 6 7 8 9 10
Do you attend an
ICD Support Group?
Yes
No 		Is there a Support
Group near you?
Yes
No 		If one WASnearby,
would you attend?
Yes
No
How valuable or important is an ICD support Group?
1=No Value - - - - - - - - - - - - - 10=Extremely Important
1 2 3 4 5 6 7 8 9 10
Has a Support Group Changed your relationship with others?
Improved It . .
No Change . . .
Hurt It . . . . . .

Rate your level of discomfort during the EP Study:
1=No Discomfort - - - - - - - - - - - 10=Extremely Uncomfortable
1 2 3 4 5 6 7 8 9 10

Based on what you have experienced,
what would you tell others anticipating an EP study?

Based on what you experienced, what PreOperation advice
would you give others scheduled for an ICD implant?

Based on what you experienced, what PostOperation advice
would you give others who receive an ICD implant?

How aware are you when you are being paced by your ICD?
1=Never Aware - - - - - - - - - - - - - - - - - - - 10=Always Aware
1 2 3 4 5 6 7 8 9 10

What does the pacing experience feel like?

The law in most states reads: "No driving for 6-months after an ICD implant
or for 6-months after ICD Therapy." Have you cheated on these rules?
(Note: We protect violators' identitities)
No - Waited or Do not Drive
Drove 1 Month Early
Drove 2 Months Early
Drove 3 Months Early
Drove 4 Months Early
Drove 5 Months Early
Drove 6 Months Early
Answer the next four items if your ICD has NEVER fired...
If your ICD has zapped you,
Skip to the next section


How worried are you about cardioversion/defibrillation?
1=Worry Free - - - - - - - - - - - - - - - - - - - 10=Extremely Worried
1 2 3 4 5 6 7 8 9 10

If still waiting for your first therapy, shock, zap...
What is the level of how the implant has changed your life?
1=Relieved - 5=Little Effect - 6=Some Effect - 10=Paralyzed with Fear
1 2 3 4 5 6 7 8 9 10


What has helped most to prepare you for the experience?

What could help you more or make the process easier?


If you have not yet experienced cardioversion/defibrillation from your ICD,
Click this link to Skip to the Next Section
You have been zapped about times in months....
Or years... (We'll do the math)

Rate your level of pain during cardioversion/defibrillation:
1=No Pain - - - - - - - - - - - - - - - - - - - - - - 10=Extremely Painful
1 2 3 4 5 6 7 8 9 10

What does it feel like and what do you experience?

Before your first therapy, shock, or zap...
How worried were you about cardioversion/defibrillation?
1=Worry Free - - - - - - - - - - - - - - - - - - - 10=Extremely Worried
1 2 3 4 5 6 7 8 9 10

After experiencing therapy, shock, or zap...
How worried are you about cardioversion/defibrillation now?
1=Worry Free - - - - - - - - - - - - - - - - - - - 10=Extremely Worried
1 2 3 4 5 6 7 8 9 10

What were you doing when you got Zapped?
Most Often . . .
Another Time:
Another Time:
Another Time:
Another Time:

Were you ever Zapped while boating or driving
and how did you handle it?


Were you ever Zapped during a flight, and what followed?


Were you ever Zapped in a tub, shower, or while swimming,
and how did you handle it?


Were you ever Zapped during love making, and what followed?


Care to share an interesting Zapping anecdote?


Do you have a second Zapping story to tell?


How about a third shocker to share with others?


What helped most to prepare you for your first zap?


Now that you have experienced cardioversion-defibrillation and
know what to expect, how has the implant has changed your life?
1=Relieved & Live More Normally - - - - 10=Paralyzed with Fear
1 2 3 4 5 6 7 8 9 10


Based on what you have experienced,
what would you tell others waiting for their first therapy?


Without your ICD, do you believe you would you be alive today?
1=Definitely No, I'd be Dead - - - 10=Definitely Yes, I'd Still be Alive
1 2 3 4 5 6 7 8 9 10

Some medical professionals inspire CONFIDENCE & TRUST. Some scare us beyond words. Tell us how you feel about your health care providers. If you have more than one in a category, grade the one you see most. If you do not see or have no contact with anyone in a following category, use the NOT APPLICABLE option.
On the following 10 is the HIGHEST - - - 1 is the LOWEST
Rate Your Cardiologist
Rate Your Electrophysiologist
Rate Your GP/PCP/Family Doctor
Rate Your Pharmacist
Rate Your Ambulance Service
Rate your Hospital Staff
Rate Your Pacemaker/ICD RN/Tech
Rate ICD (company) Rep/Field Engineer



Another important healthcare factor is SENSITIVITY & CARING. Some health care professionals seem like they are really tuned in and listening to us. Others may seem to not care less about what we say or feel. Again, if you have more than one in each category, grade the one you see most. If you do not see or have no contact with anyone in a following category, use the NOT APPLICABLE option.
On the following 10 is the HIGHEST - - - 1 is the LOWEST
Rate Your Cardiologist
Rate Your Electrophysiologist
Rate Your GP/PCP/Family Doctor
Rate Your Pharmacist
Rate Your Ambulance Service
Rate your Hospital Staff
Rate Your Pacemaker/ICD RN/Tech
Rate ICD (company) Rep/Field Engineer

What would you tell your Cardiologist
that would improve how he/she helps ICD recipients?

What would you tell your Electrophysiologist
that would improve how he/she treats ICD recipients?

What would you tell your Primary Care Physician/Family Doctor
that would improve how he/she treats ICD recipients?

What would you tell your Pharmacist
that would improve how he/she handles ICD recipients?

What would you tell your Ambulance Service
that would improve how it serves ICD recipients?

What would you tell your Hospital Staff
that would improve how they treat ICD recipients?

What would you tell your RN/Tech checking your ICD
that would improve how he/she treats ICD recipients?

What would you tell your ICD Company Rep/Field Engineer
that would improve how he/she helps ICD recipients?

What would you tell your Friends & Family Members
that would improve life for all of you?


We probably overlooked or forgot to ask something.
What else do you think needs to be said?


By submitting this form, you understand: You surrender all copyright protections and grant Duffey Cybercations free and unrestricted rights to copy, edit, duplicate, and distribute submitted material without compensation beyond providing attribution as stipulated in the privacy selection choice above.

Please check for errors or ommissions before submission.


Pay no attention to the message you get after making a submission...
you are ordering nothing (except a free copy of the finished book.)

Copyright © 1999 by The CK Trust Fund
Duplication/distribution encouraged - with attribution.