Home  |  Heartmates Foundation
Heartmates Resources  |  For Health Care Professionals  |  About Us
Heartmates Order Form | Professional Order Form
Name:
Address:
City:
State/Province:
Postal/Zip Code:
E-mail Address
Your Age: Male Female
Patient's Age: Male Female
Date of most recent cardiac Event::
What has changed most in
your life since the onset of your
mate's heart disease?

Check as many of the topics listed below about which you have
questions or concerns:
Heart disease and recovery information
Role and responsibility changes
Are my feelings / reactions normal?
Self-Care
Lifestyle Changes
Depression / Anger (mine or my partner's)
Fear / Anxiety (mine or my partner's)
Adapting to long-term changes
Loss / grief (example: lost dreams)
Communication
Physical Intimacy
Family members / children
Finances
Work / Retirement
Thank you!

Home  |  Heartmates Foundation 
Heartmates Resources  |  For Health Care Professionals  |  About Us
Heartmates Order Form | Professional Order Form

¨

H E A R T M A T E S
PO Box 16202 Minneapolis, MN 55416
612-558-3331  Fax: 603-949-6395
info@heartmates.com

© 1996 - 2007 Heartmates. All rights reserved. No image or text may be
reproduced, displayed, or transmitted without written
permission of Heartmates.

Heartmates® is a registered trademark.

WEB DESIGN BY HANDWOVEN WEBS
 
Heartmates
Foundation		   Heartmates Health Care
Professionals
Donate   Order Order
Home - Heartmates Foundation - Interactive Connections
Heartmates Resources - Health Care Professionals - About Us
 
Phone: (612) 558-3331
Fax: (952) 929-6395
E-mail: Rachael @heartmates.com
Heartmates¨ is a registered trademark.		 Heartmates, Inc.
PO Box 16202
Minneapolis, MN 55416