POTS Grant Questionnaire

Name:__________________________________________= ____________________

Birth Date: _________ &= nbsp; &nbs= p; Age:______ &= nbsp; &nbs= p; Gender: M F &nbs= p;

Height: ____________ Weight: _______________

Address:_______________________________________= ______________________

City/State/Zip Code:____________________________________________________=

Social Security Number ________________________=

Telephone: (H)____________________ (W)__________________________= _

&nb= sp; (Cell) __________________

Email Address:_________________________________= Webpage: ___________________________ <= span style=3D'mso-tab-count:1'> &= nbsp;

Ethnic group:

a. Caucasian (Non-Hispanic)

b. African-American/Black (Non-Hispanic)

c. Hispanic/White

d. Hispanic/Black

e. Asian

f. Other (please specify)____________________________

Are you currently working or going to school? Yes_____No_____

If you work, what is your curr= ent occupation?____________________________________________

How many days of work or schoo= l have you missed in the last month because of illness?_____

If no, when did you last work/= school?__________ Doing what?_________________________

Allergies

To medication?_______________________________________________________________<= o:p>

To food?____________________________________________________________________

Other?________________________= _____________________________________________

Have you been told that you have a disord= er of the autonomic nervous system? Yes_____ No_____=

If so, by whom? _____________________________________

What did they call this disorder? _____________________________________

List your medical problems (e.g., diabete= s, high blood pressure, asthma, kidney disease, stroke, cancer, heart disease, etc.)

Primary Physician’s Name:_______________________________________________

Primary Physician’s Address and phone num= ber:__________________________________________

Do you believe you have= or have you been told that you have one of the following conditions? (circle a= ll that apply)

1. mitral valve prolapse &= nbsp; &nbs= p; &= nbsp; &nbs= p; 2. chronic fatigue syndrome

3. fibromyalgia = <= span style=3D'mso-tab-count:4'> &= nbsp; &nbs= p; &= nbsp; &nbs= p; 4. irritable bowel syndrome

5. sick building syndrome &= nbsp; &nbs= p; &= nbsp; = 6. hypoglycemia

7. multiple chemical sensitivity &= nbsp; &nbs= p; &= nbsp; &nbs= p; 8. dysautonomia

Please list any diseases that y= ou have been diagnosed with and dates:

_______________________________= ___________________________________________________

Which of your problems is most troubling = to you?

What do you hope to get from your visit?<= o:p>

When and how did your current symptoms be= gin?

Please list any medications th= at you are taking:

Name &nbs= p; &= nbsp; &nbs= p; Dose (mg) &n= bsp; = ; &n= bsp; Times per day

__________________________________ _____________________________________

_______________________________________________= ________________________

Use the scale below to complete the list regarding your symptoms and their frequency/month:=

1:Never&n= bsp; 2:< 1 time 3:2-4 times 4:5-7= times 5:daily

_________________________________________= _______________________________

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; urinary incontinence or leaking

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; constipation

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; fatigue

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; nausea

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; headache

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; heartburn

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; clamminess of skin

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; tremulousness

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; impotence (for males)

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; sensation of rapid heartbeat

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; impaired memory

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; fainting

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; itching of the feet

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; chest discomfort

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; sensation of forceful, slow heartbeat

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; dizziness

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; feeling of weakness

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; frequent wakening during the night

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; shortness of breath

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; blurring or dimming of vision

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; difficulty emptying the bladder

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; excessive daytime sleepiness

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; loose, watery stools

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; anxiety

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; muscle aches

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; bloating after meals

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; itching of the hands

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; lightheadedness (faintness)

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; difficulty falling to sleep

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; difficulty with starting to urinate

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; sensation of head or room spinning

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; excessive sweating

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; confusion

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; neck or shoulder aching

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; joint aches

1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 &= nbsp; difficulty staying asleep

Please list your 3 main sympto= ms:

1) _______________________________________________________________________

2) _______________________________________________________________________

3) _______________________________________________________________________

= ;

How Frequent are these symptoms?

[ ] Never or almost never

[ ] Several times a month

[ ] Several times a week

[ ] Daily

How severe are these symptoms?

[ ] Mild

[ ] Moderate

[ ] Severe

How long have you had symptoms?

[ ] Less than 1month

[ ] 1-3 months

[ ] 6-12 months

[ ] More than 1 year

Are they improving?

[ ] Yes

[ ] No

[ ] No change

Does anyone else in the family have these sympt= oms? Who? _

Which of your mother/father/sister/brother have had:

Diabetes_________________________________= ___________________________________

High blood pressure______________________= _____________________________________

Asthma___________________________________= __________________________________

Heart disease________________________________________________________________

Kidney disease_______________________________________________________________=

Stroke___________________________________= ___________________________________

Cancer___________________________________= __________________________________

Other disease____________________________= ____________________________________

1. = On average= , how frequently do you feel dizzy or lightheaded?

&= nbsp; [ ] Almost all day long

&= nbsp; [ ] Several times a day

[ ] Once or twice a day

[ ] Several times a week

[ ] Once or twice a week

[ ] Once or twice a month<= /o:p>

[ ] Less than once a month=

2. = If you were frequently dizzy, did this begin before the illness? [ ] Ye= s [ ] No

3. = Have you ever fainted (unconscious)? [ ] Yes [ ] No

4. = Have you ever nearly fainted (not unconscious but blackout, or fell down from dizziness)? [ ] Yes [ ] No

5. = If you fainted or nearly fainted, did this begin before the illness? [ ] Yes [ ] No

6. = If you have fainted, nearly fainted, or been frequently (daily) dizzy is this related to exercise?

&n= bsp; [ ] Mostly or always occurs with exercise but not at rest

&n= bsp; [ ] Can occur without exercise but exercise makes it worse<= /p>

&n= bsp; [ ] Not related to exercise

7. = Does fainting or dizziness occur when you are standing or sitting?=

&n= bsp; [ ] Always

&n= bsp; [ ] Almost always

&n= bsp; [ ] Never

&n= bsp; [ ] Not related to posture

8. = Does fainting or dizziness get better when you lie down? [ ] Yes [ ] No

9. = Does fainting or dizziness worsen with emotion or fear? [ ] Yes [ ] No

10. = ; Are you Bedridden? [ ] Ye= s [ ] No

= &nb= sp; If yes for how long and explain ___________________________________ _________________________________________________________________

11. &= nbsp; Which stat= ement below best describes your usual desire for salt (check only one answer)

&nbs= p; [ ] I have no special craving for salt

[ ] I occasionally have a cravi= ng for salt and salty foods

[ ] I often crave salt and salty foods

12. = ; Which statement below best describes your usual degree of thirst and fl= uid consumption

[ ] I am thirsty all the time and drink frequently

[ ] I am thirsty all the time but drink a normal amount

[ ] I am normally thirsty and drink frequently

[ ] I am normally thirsty and drink a normal amount

[ ] I am rarely thirsty and drink frequently

[ ] I am rarely thirsty and drink a normal amount

[ ] I am rarely thirsty and drink infrequently

13. = How long have you had symptoms?

&n= bsp; [ ] Less than 1month

&n= bsp; [ ] 1-3 months

&n= bsp; [ ] 6-12 months

&n= bsp; [ ] More than 1 year

How often do you get the following symptoms:<= /b>

a) H= eartburn

[ ]Never or almo= st never

[ ] Several time= s a month

[ ] Several time= s a week

[ ] Daily

b) Feeling full after eating ju= st a small amount of food

[ ] Never or almost never<= /o:p>

[ ] Several times a month<= /o:p>

[ ] Several times a week

[ ] Daily

c) V= omiting or a sensation that food is coming back up from your stomach

[ ] Never or almost never<= /o:p>

[ ] Several times a month<= /o:p>

[ ] Several times a week

[ ] Daily

d) N= ausea

[ ] Never or almost never<= /o:p>

[ ] Several times a month<= /o:p>

[ ] Several times a week

[ ] Daily

e) Pain in the upper abdomen

[ ] Never or almost never

[ ] Several times a month<= /o:p>

[ ] Several times a week

[ ] Daily

f) Constipation or diarrhea

[ ] Constipation

[ ] Diarrhea<= /p>
[ ] Normal

g) Trouble with urination

[ ] No

[ ] Yes

h) Incontinence (wetting) or urinary retention

[ ] No

[ ] Incontinence

[ ] Retention=

i) Impotence

[ ] No

[ ] Yes

j) V= ertigo (room spinning)

[ ] Never or almost never<= /o:p>

[ ] Several times a month<= /o:p>

[ ] Several times a week

[ ] Daily

k) F= ast heart beat

[ ] Never or almost never<= /o:p>

[ ] Several times a month<= /o:p>

[ ] Several times a week

[ ] Daily

l) H= ave you or others observed a Pale or Gray color to your face?

[ ] Never or almost never<= /o:p>

[ ] Several times a month<= /o:p>

[ ] Several times a week

[ ] Daily

m) Discolored hands or feet

[ ] Never or almost never<= /o:p>

[ ] Several times a month<= /o:p>

[ ] Several times a week

[ ] Daily

n) C= old hands or feet

[ ] Never or almost never<= /o:p>

[ ] Several times a month<= /o:p>

[ ] Several times a week

[ ] Daily

o) D= o you have pain in your hands or feet?

[ ] Never or almost never<= /o:p>

[ ] Several times a month<= /o:p>

[ ] Several times a week

[ ] Daily

p) D= o you have pain in your legs?

[ ] Never or almost never<= /o:p>

[ ] Several times a month<= /o:p>

[ ] Several times a week

[ ] Daily

q)Ho= t and sweaty for no reason

[ ] Never or almost never<= /o:p>

[ ] Several times a month<= /o:p>

[ ] Several times a week

[ ] Daily

r)Fa= cial Flushing

[ ] Never or almost never<= /o:p>

[ ] Several times a month<= /o:p>

[ ] Several times a week

[ ] Daily

s) A= re your other symptoms worsened by environmental heat?

[ ]<= /span> Never or = almost never<= /p>
[ ] Several times a month<= /o:p>

[ ] Several times a week

[ ] Daily

t) D= o you have any breathing difficulty or feel that you do not get enough air?

[ ]<= /span> Never or = almost never<= /p>
[ ] Several times a month<= /o:p>

[ ] Several times a week

[ ] Daily

u) H= eadache or migraine

[ ] Never or almost never<= /o:p>

[ ] Several times a month<= /o:p>

[ ] Several times a week

[ ] Daily

v) L= eg weakness

[ ] Never or almost never<= /o:p>

[ ] Several times a month<= /o:p>

[ ] Several times a week

[ ] Daily

[ ] Daily but only standing up<= o:p>

w) Do you have mitral valve prolapse? [ ] Yes [ ] No

Do your symptoms occur when you= are standing or sitting?

            [ ] Always

[ ] Almost always

[ ] Never

[ ] Not related to posture

<= span style=3D'font-family:Arial;mso-no-proof:no'>

Do your symptoms get better whe= n you lie down?                     &= nbsp;   [ ] Yes [ ] No

Do your symptoms get worse with exercise ?     &nb= sp;         &= nbsp;           &= nbsp;           &= nbsp;   [ ] Yes [ ] No

Do your symptoms get worse with alcohol ?     &nbs= p;            &= nbsp;         &= nbsp;           &= nbsp;   [ ] Yes [ ] No

Do your symptoms change during = the menstrual cycle?    <= span style=3D'mso-tab-count:1'>        &= nbsp;           &= nbsp;   [ ] Yes [ ] No

Are these symptoms related to dizziness or fainting?   &nb= sp;            &= nbsp;           &= nbsp;   [ ] Yes [ ] No

Are these symptoms related to a= ny specific medication that you take? &nb= sp;     [ ] Yes [ ] No

Plea= se explain any abnormal findings

Heart Rate and Blood Pressure Recordings<= o:p>

Please record your blood pressure and hea= rt rate under the following conditions on three separate occasions. Lie quietly for 10 minutes and then take blood pressure and heart rate. Then stand in o= ne place. At the end of 3 minutes and then again at 10 minutes, take blood pressure a= nd heart rate. Record the results below. This is VERY IMPORTANT. These records cannot be properly evaluated without this information.

blood pressure

heart rate

date_____ time_____

lyi= ng

____________

_________ =

sta= nding 3 min

____________

_________ =

sta= nding 10 min

____________

_________ =

date_____ time_____

lyi= ng

____________

_________ =

sta= nding 3 min

____________

_________ =

sta= nding 10 min

____________

_________ =

date_____ time_____

lyi= ng

____________

_________ =

sta= nding 3 min

____________

_________ =

sta= nding 10 min

____________

_________ =

How were these reading taken= ?

a.

Who measured your blood pressure and heart rate?______________________ <= /o:p>

b.

Doe= s the cuff automatically make the measurements?____________________ =

c.

Did= you use an arm cuff or finger cuff.__________________________________ =

Please return this form to:

Research Coordinator

Center for Autonomic Dysfunction

New York Medical College

19 Bradhurst Avenue Suite 3050 North

Hawthorne NY = 10532

Email: yvonne_lori@n= ymc.edu

Ph: 914-593-8888

Fax: (914) 593-8890

		blood pressure	heart rate
date_____ time_____	lyi= ng	____________	_________ =
	sta= nding 3 min	____________	_________ =
	sta= nding 10 min	____________	_________ =
date_____ time_____	lyi= ng	____________	_________ =
	sta= nding 3 min	____________	_________ =
	sta= nding 10 min	____________	_________ =
date_____ time_____	lyi= ng	____________	_________ =
	sta= nding 3 min	____________	_________ =
	sta= nding 10 min	____________	_________ =
How were these reading taken= ?
a.	Who measured your blood pressure and heart rate?______________________ <= /o:p>
b.	Doe= s the cuff automatically make the measurements?____________________ =
c.	Did= you use an arm cuff or finger cuff.__________________________________ =