Questionnaire

Barostim is an implantable device that may help improve heart failure symptoms like shortness of breath and fatigue. This 2 minute questionnaire will help determine if you may be a candidate.

Has a doctor diagnosed you with heart failure?

Yes No

Which of the following describes you?
(Choose all that apply)

I struggle with daily activities, such as walking up and down the stairs, getting the mail, playing with my grandchildren My symptoms prevent me from doing the activities that I want to be able to do I am told there is nothing that can be done for my heart condition at this time My heart failure medications no longer make me feel better None of the above

What is your heart’s ejection fraction (the percentage of your heart’s function)?

35% Or Less More than 35% Don't know

Do you have (or have you been told you need) either

An implantable defibrillator (ICD), or
A three-lead implantable device to help both sides of your heart beat together (CRT)?

Yes No

Do you have a left ventricular assist device (LVAD)?

Yes No

Is Barostim Right For Me?

Has a doctor diagnosed you with heart failure?

Which of the following describes you?
(Choose all that apply)

What is your heart’s ejection fraction (the percentage of your heart’s function)?

Do you have (or have you been told you need) either

Do you have a left ventricular assist device (LVAD)?

To learn if you may qualify for Barostim, submit your information below and see your results immediately.

Is Barostim Right For Me?

Has a doctor diagnosed you with heart failure?

Which of the following describes you? (Choose all that apply)

What is your heart’s ejection fraction (the percentage of your heart’s function)?

Do you have (or have you been told you need) either

Do you have a left ventricular assist device (LVAD)?

To learn if you may qualify for Barostim, submit your information below and see your results immediately.

Which of the following describes you?
(Choose all that apply)