Vanderbilt University Autonomic Dysfunction Center Autonomic Dysfunction Questionnaire
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- Meryl Phillips
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1 Vanderbilt University Autonomic Dysfunction Center Autonomic Dysfunction Questionnaire Name: Date: Address: Phone number:( ) address: Birth date: / / Age: Sex: M F Height Weight 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? Yes No If yes, what is your current occupation? How many days of work have you missed in the last month because of illness? If no, when did you last work? Doing what? Allergies To medication? To food? Other? 1 of 5
2 Have you been told that you have a disorder of the autonomic nervous system? Yes If so, by whom? What did they call this disorder? No List your medical problems (e.g., diabetes, high blood pressure, asthma, kidney disease, stroke, cancer, heart disease, etc.) Do you believe you have or have you been told that you have one of the following conditions? (circle all that apply) 1. mitral valve prolapse 2. chronic fatigue syndrome 3. fibromyalgia 4. irritable bowel syndrome 5. sick building syndrome 6. hypoglycemia 7. multiple chemical sensitivity Which of your problems is most troubling to you? What do you hope to get out of your stay at the Autonomic Dysfunction Center? When and how did your current symptoms begin? 2 of 5
3 Current medications Please list all of your current medications. Please include all prescription, non-prescription, and herbal preparations: Name Dose (mg) Times per day Family History Which of your mother/father/sister/brother have had: Diabetes High blood pressure Asthma Heart disease Kidney disease Stroke Cancer Other disease 3 of 5
4 Use the scale below to complete the list regarding your symptoms and their frequency: 1:Never 2:< 1 time 3:2-4 times 4:5-7 times 5:daily a month a month a month urinary incontinence or leaking constipation fatigue nausea headache heartburn clamminess of skin tremulousness impotence (for males) sensation of rapid heartbeat impaired memory fainting itching of the feet chest discomfort sensation of forceful, slow heartbeat dizziness feeling of weakness frequent wakening during the night shortness of breath blurring or dimming of vision difficulty emptying the bladder excessive daytime sleepiness loose, watery stools anxiety muscle aches bloating after meals itching of the hands lightheadedness (faintness) difficulty falling to sleep difficulty with starting to urinate sensation of head or room spinning excessive sweating confusion neck or shoulder aching joint aches difficulty staying asleep 4 of 5
5 Heart Rate and Blood Pressure Recordings Please record your blood pressure and heart 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 one place. At the end of 3 minutes and then again at 10 minutes, take blood pressure and heart rate. Record the results below. This is VERY IMPORTANT. These records cannot be properly evaluated without this information. blood pressure heart rate How were these reading taken? a. Who measured your blood pressure and heart rate? b. Does the cuff automatically make the measurements? c. Did you use an arm cuff or finger cuff. Please return this form to: Referral Nurse Autonomic Dysfunction Service AA-3228 Medical Center North Vanderbilt University Medical Center Nashville, TN Fax: (615) of 5
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ADHD Evaluation Intake Form Patient Contact Information Patient Name: Date of Birth: Age: Last First MI Address: Email address: Contact phone number: Emergency Contact/Number/Relationship: Pharmacy: Primary
New Client Intake. First Name Last Name. Address. City State Zipcode Date of Birth. Home Phone Mobile Phone. Relationship to you Phone
1 New Client Intake Address City State Zipcode Date of Birth Home Phone Mobile Phone Emergency Contact: Relationship to you Phone Please explain the pain you are experiencing and its origin story: https://docs.google.com/document/d/1q0tns8lwtefzbbj1n9jyt2onopvy2abs9s1ofr07zai/edit