Zap•Life
Health Care Professional - Submission Form
Contributer's Name:

(TYPE OVER/REPLACE)
Relationship to ICD Recipients:

Employer
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
What percentage of your patients have an ICD? %

Have you attended an
ICD Support Group?
Yes
No 		Has a support Group Changed Your
Relationship with your Patients?
Improved It . . .
No Change . . .
Hurt It . . . . . .

Do you urge your patients to attend an ICD support Group?
1=Never - - - - - - - - - - - - - 10=Always

1 2 3 4 5 6 7 8 9 10


If you have ever helped start or maintain an ICD support group,
what advice would you give others making the same effort?


Based on your experience....

What PreOperation advice
do you give candidates for an ICD implant?

What PreOperation advice
do you give the family and friends of ICD candidates?

What PostOperation advice
do you give new ICD recipients?

What PostOperation advice
do you give family and friends of ICD recipients?

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

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?


For the remaining questions, do you want your
identity revealed with your statements, or kept secret?
Make ID Public
Keep ID Secret
Health care professionals interact with many other professionals on a daily basis. In such a capacity you probably see many ways others could improve how they deal with people with arrhythmia problems and their families. What "hints" do you think would assist others listed below?


What would you tell a Cardiologist?



What would you tell an Electrophysiologist?


What would you tell Primary Care Physicians/Family Doctors?


What would you tell Pharmacists?


What would you tell an EMT or Ambulance Service Administrator?


What would you tell other members of a Hospital Staff?


What would you tell the RN/Tech checking ICD implants?


What would you tell the ICD Company Rep/Field Engineer?


Finally, what advice do you give to family members or
friends of an ICD recipient to improve their relationships?


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


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Please check for errors or ommissions before submission.


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