The first part of this guide lists how to get all the heart pieces. It contains some light spoilers, but I tried to obfuscate them where I could. The following sections go more in-depth on how to get specific heart pieces.

Note that the pause and file select menus will only show 3 health upgrades, but you can actually get 4 extra hearts if you get all of the pieces. These are the only things I know of that will cause you to miss them:

• Keeping the gem.
  
• Telling on Brad.
  
• Going to the mines before getting the first 5 heart pieces.
  
• Giving Marle the shipping label before getting the last 3 heart pieces.

1. Depending on who you give the gem to in Orwell, you will find either Sewert (the guy in the sewer) or the merchant (from in front of the Cult-45 hideout) In Allendale later in the game. Sewert will give you a heart piece, while you will have to buy one from the merchant for $250. To my knowledge, you can't get this piece if you keep the gem.
   
2. When you complete the "O Well" quest in Orwell, the mayor will give you the deed to his room in Allendale. The heart piece is in the chest at the top of this room.
   
3. Speak to the barrel guy that the cops were talking to outside of Allendale to get the "Hide and Seek" quest. Completing it gets you another piece.
   
4. When asked, tell Dregs (the big grey scrapper) that you snuck into the scrapyard. Depending on what you do next, you will either get a heart piece after the ensuing boss fight, or Brad (the door guard guy) will give you a heart piece when you talk to him after meeting with Marle.
   
5. Buy the motor from Bill's Pills in Allendale for $100, then give it to the broken robot on the way out of the scrapyard.

1. During the escape, Connie will ask if you want to try to take a crude crystal. If you don't take it, the owner of the Speakeasy in Allendale will give you a heart piece. If you do take it, Connie will give you a heart piece in the room next to yours in the hostel in Allendale.
   
2. In Orwell, Eli will give you the "Reunion" quest. Finish this quest for a heart piece.
   
3. Speak to Father Wormwood at Basecamp. Doing this quest will lead to the "All Wraiths Must Die" quest. Finish this quest for the last heart piece.

What you do with the gem is the first decision you can make that will affect a heart piece, but you will not actually receive it until returning to Allendale after the time skip.

As part of the story, you will receive the jail cell keys for the Cult-45 hideout.

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On the way out of the hideout, you can circle back to a side path that formerly led to a dead end.

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At the end will be a door you can unlock with the jail cell keys.

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Behind this door is the path to a chest that contains the gem. You will have to fight 2 gorehounds and a flying turret on the way.

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Once you have the gem, you can give it to the merchant outside of the Cult-45 hideout or Sewert (the critter griller in the Orwell sewers). You can also choose to not give it to either, but you will not be able to get this heart piece if you keep the gem.

After the time skip, the merchant will have a shop in Allendale where Bill's Pills used to be. He will sell you a heart piece for $250.

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After the time skip, Sewert will be set up in Allendale where Bill's Pills used to be. He will give you a heart piece as thanks for giving him the gem.

After returning to Orwell from the Cult-45 hideout, the mayor will ask you to find the missing "R" from the Orwell sign, starting the O Well quest.

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Go to the house on the left side of the Orwell sign.

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On the top floor of the house is a locked chest. Open it with the combination "GEM." (If you talk to Oli to the left of the house a couple times, he will be practicing spelling this word.) Pick up the "R" that comes out of the chest.

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Return to the mayor. Your choice to tell on Oli or say the cult members stole the letter only makes a slight difference in dialog from Oli. The mayor will give you the deed to a room in Allendale. To get to the hostel, go to Allendale and look on the left for a door with a bed sign.

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Give the deed to the woman who runs the hostel.

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She will give you the key to your room upstairs.

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The heart piece is in the chest at the top of the room.

While continuing the story through Allendale, you will see cutscenes featuring a man holding a barrel (or something similar) trying to divert the Parasol Troopers from his nephew. If you speak to him outside Allendale, he'll ask you to find his nephew, starting the "Hide and Seek" quest. You do not need to speak with him to complete the quest.

The boy is hiding in a cave on the lower path to the left of Allendale, on the way to the fishing hole. In the bottom-left corner of a screen on this path, you will see a little waterfall. Go through the waterfall to enter the cave.

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The cave is full of thorns and (if you've defeated both of the Allendale bosses in the main quest) wraiths. At the end of the cave, you will find the boy. He's hurt himself and can't walk, so you will need to give him a piggy-back ride back out of the cave, disabling your ability to use the gunbrella.

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Back at the entrance, uncle and nephew will be reunited. The uncle will give you a heart piece to show his thanks.

As you progress through the story, you will end up in a scrapyard. About halfway through this area, you will encounter Dregs, the big grey scrapper. He will ask how you got into the scrapyard. Tell him you snuck in. If you tell on Brad, you won't be able to get the heart piece. Dregs will attack you. After you have beaten him, he will tell you to finish him off.

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If you do, you will get the heart piece from killing him.

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You can also wait until the doors open and leave without killing him. If you do, Brad will be waiting for you outside of the cafeteria after you've killed the giant rat. He will offer to show you a shortcut through the scrapyard. Take the shortcut to skip a large section you'd otherwise have to backtrack through.

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At the other side of the shortcut, talk to Brad again to get the heart piece.

Buy a motor for $100 from the Bill's Pills in Allendale.

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On the way out of the Scrapyard (on the same screen Brad will take you to if you go through his shortcut), you will find a broken robot. Give him the motor to get a heart piece.

During the escape from the mines, Connie will ask if you want to take some of the crude from the mines as "reparations." You can get a heart piece with either choice, but there are negatives to both:

• Taking the crude gives you two items that sell for $150 each, but Hoag dies.
  
• Not taking the crude allows Hoag to live, but you miss out on $300.

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If Hoag lives, Barbara (the barkeep in Allendale) will give you a heart piece.

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If Hoag dies, Connie will give you a heart piece when you visit her room in Allendale. The room is next door to yours.

In the remains of Orwell, Eli will be searching for his son, Oli. Speaking with him will start the "Reunion" quest.

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Go left from Orwell, then take the lower-left exit.

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Oli is on the left side of this room.

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Give Oli a piggy-back ride back to Eli to get this heart piece.

On the way back to civilization from the mines, stop by the church at Basecamp.

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Talk to Father Wormwood and accept his commission to get holy shells capable of permanently killing wraiths.

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Go to the graveyard to the right of the church.

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In the graveyard, go to the left. On this screen, shoot the bell with the holy shells and kill the wraith that appears.

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On the way out of the graveyard, speak with Scarlett to start the "All Wraiths Must Die" quest. (Scarlett will be there and give you the quest even if you have never spoken to her before.)

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If you visit her at the previous Cult-45 hideout, she will ask you to kill a total of 16 wraiths to show that you're serious about helping her. (This is not a required step.)

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Besides the one you've already killed in the graveyard, there are 15 wraiths available to slay:

• 5 on the outskirts of Allendale. Go two screens left out of the town for 2, go up for 2 more, then left another screen for the last 1.
  
• 5 on the outskirts of Orwell. Go one screen left of the town for 2, then take the upper-left exit for 3 more.
  
• 5 in the Orwell Sewers. Go down into the sewers, then to the right for 2. Go right, up the shaft, then left for the last 3.

When you return to the Cult-45 hideout, Scarlett will be gone. However, you will now be able to go further in. Go through the hideout until you run into Scarlett. You will have to team up with her to fight an onslaught of wraiths, including a unique, tougher wraith. Once the dust clears, Scarlett will give you the heart piece.