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Intake questionnaire

CCM OPEN HF Registry

Applying to Henry Ford Providence Hospital · Novi, Michigan

Answer a few short questions to share with the research team.

0 of 3 answered

1. Are you 18 years old or older?

YesNo

2. Have you been diagnosed with Heart Failure?

YesNo

3. Are you able to travel to Novi for study visits?

YesNo

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Completing a questionnaire on Clinably does not enroll you in a clinical trial or confirm your eligibility. Only the research team can determine whether you meet the criteria to participate. Results are based on the information you provide and are intended to help you start a conversation with the research team.

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