Vanderbilt Autonomic Dysfunction Center

Vanderbilt Autonomic Dysfunction Center

David Robertson, MD
Italo Biaggioni, MD
Satish Raj, MD

Cyndya Shibao, MD

Vanderbilt Autonomic Dysfunction Center
Initial Questionnaire

I. Contact Information
Name: ________________________________________________________________

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 inappropriate
tachycardia (rapid heart beat) on standing

□ Inappropriate Sinus Tachycardia (IST)
□ Pure Autonomic Failure (PAF)
□ Multiple System Atrophy (MSA) or Shy-Drager Syndrome (SDS)
□ Parkinson’s 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 Diagnosis

1. __________________________ 5. ______________________________

2. __________________________ 6._______________________________

3. __________________________ 7. ______________________________

4. __________________________ 8. _______________________________

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

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Revised 04-06-2012

Vanderbilt Autonomic Dysfunction Center

David Robertson, MD
Italo Biaggioni, MD
Satish Raj, MD

Cyndya Shibao, MD

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 Medications

Name of Medication Dose Time of day you take medication
___________________________
_____________________________ ______ ___________________________
___________________________
_____________________________ ______ ___________________________
___________________________
_____________________________ ______ ___________________________
___________________________
_____________________________ ______

_____________________________ ______

_____________________________ ______

_____________________________ ______

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

VIII. Primary Care Physician:

Name: _________________________________________

Name of Hospital / Clinic: _________________________________________

Address: _________________________________________

City, State, Zip: _________________________________________

Phone Number: _________________________________________

Fax Number: _________________________________________

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Revised 04-06-2012

Vanderbilt Autonomic Dysfunction Center David Robertson, MD
Italo Biaggioni, MD
Patient Name: ____________________________ Satish Raj, MD

Cyndya Shibao, MD

IX. Your Blood Pressure and Heart Rate:

Please take your blood pressure AND heart rate while lying down and standing on three separate
occasions, preferably early in the morning at least 2 hours after a meal. You can have this done by
a nurse in your doctor’s office or you can have a caregiver help you do this if you have a home
blood pressure machine. This is a very important part of our evaluation.

1st Measurement Lying down Blood Pressure Heart Rate
Date: ________ Standing up for one minute ____________ __________
Standing up for three minutes ____________ __________
Time: ________ Standing up for five minutes ____________ __________
____________ __________

2nd Measurement Lying down ____________ __________
Date: _______ Standing up for one minute ____________ __________
____________ __________
Standing up for three minutes ____________ __________
Time: _______ Standing up for five minutes

3rd Measurement Lying down ____________ __________
____________ __________
Date: ______ Standing up for one minute ____________ __________
____________ __________
Standing up for three minutes

Time: ______ Standing up for five minutes

Please Mail or Fax to: Autonomic Dysfunction Center Screening

Vanderbilt University
1161 21st Ave South, MCN, Room AA3228

Nashville, TN 37232

FAX: 615-343-8649

[email protected]

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Revised 04-06-2012