Q1. Is your lifestyle limited by angina pain?
Yes	No	Sometimes

Q2. Do you suffer from angina at rest or with minimal exertion?
Yes	No	Sometimes

Q3. Are you taking multiple cardiac medications?
Yes	No

Q4. Have you experienced numerous cardiac procedures?
Yes	No

Q5. Have you been referred by your cardiologist for a coronary bypass procedure?
Yes	No

Q6. Do you suffer from:
Diabetes	Hypertension

The survey is complete. Please fill out the information below and click submit.

	First Name*
	Last Name
	Address1
	Address2
	City**
	State**	--Select State-- AL Alabama AK Alaska AZ Arizona AR Arkansas CA California CO Colorado CT Connecticut DE Delaware DC District of Columbia FL Florida GA Georgia HI Hawaii ID Idaho IL Illinois IN Indiana IA Iowa KS Kansas KY Kentucky LA Louisiana ME Maine MD Maryland MA Massachusetts MI Michigan MN Minnesota MS Mississippi MO Missouri MT Montana NE Nebraska NV Nevada NH New Hampshire NJ New Jersey NM New Mexico NY New York NC North Carolina ND North Dakota OH Ohio OK Oklahoma OR Oregon PA Pennsylvania RI Rhode Island SC South Carolina SD South Dakota TN Tennessee TX Texas UT Utah VT Vermont VA Virginia WA Washington WV West Virginia WI Wisconsin WY Wyoming
	Zip**
	Country	[--Select Country--] Canada China Germany Italy Latvia Norway Poland Spain Thailand United Kingdom United States
	Email
		* required fields ** required for USA