Zap•Life
Family Member or Friend - Submission Form
Contributer's Name:

(TYPE OVER/REPLACE)
Relationship to ICD Recipient:
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

How has life with an ICD recipient changed you?
1=No Impact - - - - - - - - - - 10=Severe Impact
1 2 3 4 5 6 7 8 9 10

Is this impact Negative or Positive?
1=Extremely Negative - - - - - - 10=Extremely Positive
1 2 3 4 5 6 7 8 9 10

How has the addition of an ICD affected your relationship?

Have you attended an
ICD Support Group?
Yes.... I have
No.. I have not
None Available
If a Support Group
is not available...
I would attend
I would not go
if a group was available

Has a support Group Changed Your
Relationship with an ICD Recipient?
Improved It . .
No Change . . .
Hurt It . . . . . .

Based on what you experienced, what PreOperation advice
would you give friends and family members of people getting an ICD?

Based on what you experienced, what PostOperation advice
would you give friends and family members of people getting an ICD?

Were you ever touching an ICD recipient when he or she
received "therapy?" If so, what did it feel like to you?

What has helped most to prepare you for the experience?

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?


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 the Cardiologist treating
your Family Member or Friend
Rate the Electrophysiologist
treating your Family Member or Friend
Rate Your GP/PCP/Family Doctor
Rate Your Pharmacist
Rate Your Ambulance Service
Rate your Hospital Staff
Rate the Pacemaker/ICD RN/Tech who
sees your Family Member or Friend
Rate the 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 the Cardiologist treating your
Family Member or Friend
Rate the Electrophysiologist treating your
Family Member or Friend
Rate Your GP/PCP/Family Doctor
Rate Your Pharmacist
Rate Your Ambulance Service
Rate your Hospital Staff
Rate the Pacemaker/ICD RN/Tech who
sees your Family Member or Friend
Rate ICD (company) Rep/Field Engineer

What would you tell the Cardiologist
to improve how he/she helps ICD recipients, family members, and friends?

What would you tell the Electrophysiologist
to improve how he/she helps ICD recipients, family members, and friends?

What would you tell your Primary Care Physician/Family Doctor
to improve how he/she helps ICD recipients, family members, and friends?

What would you tell your Pharmacist
to improve how he/she helps ICD recipients, family members, and friends?

What would you tell your Ambulance Service
to improve how he/she helps ICD recipients, family members, and friends?

What would you tell your Hospital Staff
to improve how he/she helps ICD recipients, family members, and friends?

What would you tell the RN/Tech checking your ICD
to improve how he/she helps ICD recipients, family members, and friends?

What would you tell the ICD Company Rep/Field Engineer
to improve how he/she helps ICD recipients, family members, and friends?

What do you tell your ICD Recipient Family Member or Friend
to improve how he/she lives with the ICD recipients?


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 Trsut Fund
Duplication/distribution encouraged - with attribution.