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.
IV.
Other Medical Problems or Diagnosis
1. __________________________
5. ______________________________
2. __________________________
6._______________________________
3. __________________________
7. ______________________________
4. __________________________
8. _______________________________
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?
No
VIII.
Primary Care Physician:
Name:
Yes
How much? __________ (packs per day)
_________________________________________
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
Satish Raj, MD
Cyndya Shibao, MD
Patient Name:
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.
Blood Pressure
Heart Rate
1st Measurement
Lying down
____________
__________
Date: ________
Standing up for one minute
____________
__________
Standing up for three minutes
____________
__________
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
____________
__________
Standing up for five minutes
____________
__________
Time: ________
Time: ______
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
adcresearch@vanderbilt.edu
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Revised 04-06-2012