Type 2 diabetes. Chronic low back pain and joint deterioration. Cardiovascular diseases is at greater risk for diabetes, and diabetic adults are at …
Name:______________________________________________________________
Birth Date: _________ Age:______ Gender: M
F
Height: ____________ Weight: _______________
Address:_____________________________________________________________
City/State/Zip Code:____________________________________________________
Social Security Number ________________________
Telephone: H____________________ W___________________________
Cell __________________
Email Address:_________________________________Webpage:
___________________________
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 current
occupation?____________________________________________
How many days of work or school have you missed in the last month because
of illness?_____
If no, when did you last work/school?__________
Doing
what?_________________________
Allergies
To
medication?_______________________________________________________________
To
food?____________________________________________________________________
Other?_____________________________________________________________________
Have you been told that you have a disorder of the autonomic nervous
system? Yes_____ No_____
If so, by whom? _____________________________________
What did they call this disorder? _____________________________________
List your medical problems eg, diabetes, high blood pressure, asthma,
kidney disease, stroke, cancer, heart disease, etc
Primary Physicians Name:_______________________________________________
Primary Physicians Address and phone
number:__________________________________________
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 8 dysautonomia
Please list
any diseases that you have been diagnosed with and dates:
____________________________________________________________________________
______
____________________________________________________________________________
______
____________________________________________________________________________
______
____________________________________________________________________________
______
Which of your problems is most troubling to you?
What do you hope to get from your visit?
When and how did your current symptoms begin?
Please list any medications that you are taking:
Name Dose mg Times per day
__________________________________ _____________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Use the scale below to complete the list regarding your symptoms and their
frequency/month:
1:Never 2: 1 time 3:2-4 times 4:5-7 times 5:daily
________________________________________________________________________
1 2 3
4 5 urinary incontinence or leaking
1 2 3 4 5 constipation
1 2 3 4 5 fatigue
1 2 3 4 5 nausea
1 2 3 4 5 headache
1 2 3 4 5 heartburn
1 2 3 4 5 clamminess of skin
1 2 3 4 5 tremulousness
1 2 3 4 5 impotence for males
1 2 3 4 5 sensation of rapid heartbeat
1 2 3 4 5 impaired memory
1 2 3 4 5 fainting
1 2 3 4 5 itching of the feet
1 2 3 4 5 chest discomfort
1 2 3 4 5 sensation of forceful, slow heartbeat
1 2 3 4 5 dizziness
1 2 3 4 5 feeling of weakness
1 2 3 4 5 frequent wakening during the night
1 2 3 4 5 shortness of breath
1 2 3 4 5 blurring or dimming of vision
1 2 3 4 5 difficulty emptying the bladder
1 2 3 4 5 excessive daytime sleepiness
1 2 3 4 5 loose, watery stools
1 2 3 4 5 anxiety
1 2 3 4 5 muscle aches
1 2 3
4 5 bloating after meals
1 2 3 4 5 itching of the hands
1 2 3 4 5 lightheadedness faintness
1 2 3 4 5 difficulty falling to sleep
1 2 3 4 5 difficulty with starting to urinate
1 2 3 4 5 sensation of head or room spinning
1 2 3 4 5 excessive sweating
1 2 3 4 5 confusion
1 2 3 4 5 neck or shoulder aching
1 2 3 4 5 joint aches
1 2 3 4 5 difficulty staying asleep
Please list your 3 main symptoms:
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 symptoms? 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?
[ ] Almost all day long
[ ] Several times a day
[ ] Once or twice a day
[ ] Several times a week
[ ] Once or twice a week
[ ] Once or twice a month
[ ] Less than once a month
2 If you were frequently dizzy, did this begin before the illness? [ ]
Yes [ ] 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?
[ ] Mostly or always occurs with exercise but not at rest
[ ] Can occur without exercise but exercise makes it worse
[ ] Not related to exercise
7 Does fainting or dizziness occur when you are standing or sitting?
[ ] Always
[ ] Almost always
[ ] Never
[ ] 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? [ ] Yes [ ] No
If yes for how long and explain
___________________________________
_________________________________________________________________
11 Which statement below best describes your usual desire for salt check
only one answer
[ ] I have no special craving for salt
[ ] I occasionally have a craving for salt and salty foods
[ ] I often crave
salt and salty foods
12 Which statement below best describes your usual degree of thirst and
fluid 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?
[ ] Less than 1month
[ ] 1-3 months
[ ] 6-12 months
[ ] More than 1 year
How often do you get the following symptoms:
a Heartburn
[ ]Never or almost never
[ ] Several times a month
[ ] Several times a week
[ ] Daily
b Feeling full after eating just a small amount of food
[ ] Never or almost never
[ ] Several times a month
[ ] Several times a week
[ ] Daily
c Vomiting or a sensation that food is coming back up from your stomach
[ ] Never or almost never
[ ] Several times a month
[ ] Several times a week
[ ] Daily
d Nausea
[ ] Never or almost never
[ ] Several times a month
[ ] Several times a week
[ ] Daily
e Pain in the upper abdomen
[ ] Never or almost never
[ ] Several times a month
[ ] Several times a week
[ ] Daily
f Constipation or diarrhea
[ ] Constipation
[ ] Diarrhea
[ ] Normal
g Trouble with urination
[ ] No
[ ] Yes
h Incontinence wetting or urinary retention
[ ] No
[ ] Incontinence
[ ] Retention
i Impotence
[ ] No
[ ] Yes
j Vertigo room spinning
[ ] Never or almost never
[ ] Several times a month
[ ] Several times a week
[ ] Daily
k Fast heart beat
[ ] Never or almost never
[ ] Several times a month
[ ] Several times a week
[ ] Daily
l Have you or others observed a Pale or Gray color to your face?
[ ] Never or almost never
[ ] Several times a month
[ ] Several times a week
[ ] Daily
m Discolored hands or feet
[ ] Never or almost never
[ ] Several times a month
[ ] Several times a week
[ ] Daily
n Cold hands or feet
[ ] Never or almost never
[ ] Several times a month
[ ] Several times a week
[ ] Daily
o Do you have pain in
your hands or feet?
[ ] Never or almost never
[ ] Several times a month
[ ] Several times a week
[ ] Daily
p Do you have pain in your legs?
[ ] Never or almost never
[ ] Several times a month
[ ] Several times a week
[ ] Daily
qHot and sweaty for no reason
[ ] Never or almost never
[ ] Several times a month
[ ] Several times a week
[ ] Daily
rFacial Flushing
[ ] Never or almost never
[ ] Several times a month
[ ] Several times a week
[ ] Daily
s Are your other symptoms worsened by environmental heat?
[ ] Never or almost never
[ ] Several times a month
[ ] Several times a week
[ ] Daily
t Do you have any breathing difficulty or feel that you do not get enough
air?
[ ] Never or almost never
[ ] Several times a month
[ ] Several times a week
[ ] Daily
u Headache or migraine
[ ] Never or almost never
[ ] Several times a month
[ ] Several times a week
[ ] Daily
v Leg weakness
[ ] Never or almost never
[ ] Several times a month
[ ] Several times a week
[ ] Daily
[ ] Daily but only standing up
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
Do your symptoms get better when you lie down? [ ] Yes [ ]
No
Do your symptoms get worse with exercise ? [ ] Yes [ ]
No
Do your symptoms get worse with alcohol ? [ ] Yes [ ]
No
Do your symptoms change during the menstrual cycle? [ ] Yes
[ ] No
Are these symptoms related to dizziness or fainting? [ ] Yes
[ ] No
Are these symptoms related to any specific medication that you take? [
] Yes [ ] No
Please explain any abnormal findings
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 |
|date_____ time_____ |lying |____________ |_________ |
| |standing 3 min |____________ |_________ |
| |standing 10 min |____________ |_________ |
|date_____ time_____ |lying |____________ |_________ |
| |standing 3 min |____________ |_________ |
| |standing 10 min |____________ |_________ |
|date_____ time_____ |lying |____________ |_________ |
| |standing 3 min |____________ |_________ |
| |standing 10 min |____________ |_________ |
|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:
Research Coordinator
Center for Autonomic Dysfunction
New York Medical College
19 Bradhurst Avenue Suite 3050 North
Hawthorne NY 10532
Email: yvonne_lori@nymcedu
Ph: 914-593-8888
Fax: 914 593-8890
Source:nymc.edu
