Candidate Screening

Are you still experiencing heart failure symptoms despite being on medications prescribed by your doctor for heart failure?*

Yes

No

Fill in the blank: My symptoms __________ my ability to do basic activities of daily living.*

Do not impact

Sometimes impact

Always impact

Can you tell us about some of your current symptoms? (choose all that apply)*

Difficulty breathing during times of rest

Difficulty breathing during activity

Difficulty breathing while trying to sleep

Swelling in abdomen, legs, ankles, and/or feet

Difficulty climbing a full flight of stairs

Do you know your heart's pumping ability (ejection fraction)?*

Yes, > 60%

Yes, 45 - 60%

Yes, 25 – 45%

Yes, < 25%

I don’t know my EF

One last step...Please tell us about yourself to see if you may be a candidate for CCM therapy. This information will only be used by Impulse Dynamics and will not be sold to a third party.

First Name*

Last Name*

Zip Code*

Country

Email*

Phone*

Click here if you are submitting on behalf of a loved one:

Yes, I am submitting on behalf of a loved one

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UUID

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Entry Date

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Quiz Score Total

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Quiz Data

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Patient ID

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Are you a candidate for CCM® Therapy?

Are you a candidate for CCM^® Therapy?