Vasovagal Syncope Questionnaires 



1) Syncope Questionnaire


2) Autonomic OI Short Form

3) Mayo-Autonomic Symptom Profile

4) Mayo-COMPASS 31

5) Dietary Questionnaire


 


 

Questionnaire

If you are interested in becoming a participant in this study, you must be screened to determine your eligibility. This screening is done via the linked Syncope Questionnaire, and the Autonomic OI short form which you may print, fill out and mail, email or fax  to the Principal Investigator or to courtney_terilli@nymc.edu.

The remaining forms can be filled out also if you plan to enter the study 

Julian M. Stewart MD, PhD
New York Medical College
19 Bradhurst Ave. Suite 1600
Hawthorne, NY 10532

The downloaded screening questionnaire (pdf) requires postage to mail or you can attach it as an Email attachment to stewart@nymc.edu  or you can also fax us a copy at 914-593-8890. 

If you are unable to view or print this form and still desire to find out about your eligibility, please contact the investigators at the above address or at stewart@nymc.edu and you will be mailed a copy.