7/27/2019 Autonomic Dysfunction Questionnaire

1/3

Vanderbilt Autonomic Dysfunction CenterDavid Robertson, MD

Italo Biaggioni, MDSatish Raj, MD

Cyndya Shibao, MD

1Revised 04-06-2012

Vanderbilt Autonomic Dysfunction CenterInitial Questionnaire

I. Contact InformationName: ________________________________________________________________

Age: _________ Date of birth: ______________ Sex: _____ Female ____ Male

Home Address: _________________________________________________________

City: ______________________ State _____________ Zip __________

Social Security Number: ___________________

Home Phone: ___________________ Cell phone: _______________________

Email Address: __________________________________________________________

II. Prior Diagnosis: Has a physician ever told you that you had:

Postural Tachycardia syndrome (POTS) or orthostatic intolerance or inappropriatetachycardia (rapid heart beat) on standing

Inappropriate Sinus Tachycardia (IST) Pure Autonomic Failure (PAF) Multiple System Atrophy (MSA) or Shy-Drager Syndrome (SDS) Parkinsons Disease with orthostatic hypotension or autonomic dysfunction Diabetes Mellitus (high blood sugar) with autonomic dysfunction

Syncope (passing out spells) Orthostatic hypotension Other (please describe): __________________________________________________

III. Other Medical Problems or Diagnosis1. __________________________ 5. ______________________________

2.__________________________ 6._______________________________

3. __________________________ 7. ______________________________

4. __________________________ 8. _______________________________

IV. Which of your problems is the most troubling to you?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

7/27/2019 Autonomic Dysfunction Questionnaire

2/3

Vanderbilt Autonomic Dysfunction CenterDavid Robertson, MD

Italo Biaggioni, MDSatish Raj, MD

Cyndya Shibao, MD

2Revised 04-06-2012

Patient Name: ____________________________

V. Do you have any allergies to food or medications? Yes No

If yes, please explain, including the reaction you experience.__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

VI. Current MedicationsName of Medication Dose Time of day you take medication_____________________________ ______ ___________________________

_____________________________ ______ ___________________________

_____________________________ ______ ___________________________

_____________________________ ______ ___________________________

_____________________________ ______ ___________________________

_____________________________ ______ ___________________________

_____________________________ ______ ___________________________

VII. Do you currently smoke? Yes No How much? __________ (packs per day)

VIII. Primary Care Physic ian:

Name: _________________________________________

Name of Hospital / Clinic: _________________________________________

Address: _________________________________________

City, State, Zip: _________________________________________

Phone Number: _________________________________________

Fax Number: _________________________________________

7/27/2019 Autonomic Dysfunction Questionnaire

3/3

Vanderbilt Autonomic Dysfunction CenterDavid Robertson, MD

Italo Biaggioni, MDSatish Raj, MD

Cyndya Shibao, MD

3Revised 04-06-2012

Patient Name: ____________________________

IX. Your Blood Pressure and Heart Rate:

Please take your blood pressure AND heart rate while lying down and standing on three separateoccasions, preferably early in the morning at least 2 hours after a meal

. You can have this done bya nurse in your doctors office or you can have a caregiver help you do this if you have a homeblood pressure machine. This is a very important part of our evaluation.

Blood Pressure Heart Rate

1st Measurement

Date: ________ Standing up for one minute ____________ __________

Lying down ____________ __________

Standing up for three minutes ____________ __________

Time: ________ Standing up for five minutes ____________ __________

2nd Measurement

Date: _______ Standing up for one minute ____________ __________

Lying down ____________ __________

Standing up for three minutes ____________ __________

Time: _______ Standing up for five minutes ____________ __________

3rd Measurement

Date: ______ Standing up for one minute ____________ __________

Lying down ____________ __________

Standing up for three minutes ____________ __________

Time: ______ Standing up for five minutes ____________ __________

Please Mail or Fax to: Autonomic Dysfunction Center ScreeningVanderbilt University1161 21st Ave South, MCN, Room AA3228Nashville, TN 37232FAX: 615-343-8649adcresearch@vanderbilt.edu

mailto:adcresearch@vanderbilt.edumailto:adcresearch@vanderbilt.edumailto:adcresearch@vanderbilt.edu