REX Health



1800225000Dysautonomia New Patient QuestionnaireDr. Sameh MobarekGENERALWho referred you for today’s consultation? _________________________________________________When did your symptoms begin? _________________________________________________________Did anything seem to trigger the onset of your symptoms such as infection, viral illness, surgery, trauma, concussion, vaccination, pregnancy, or delivery?________________________________________________________________________________________________________________________________________________________________________What are your worst/most bothersome symptoms?1. __________________________________________________________________________________2. __________________________________________________________________________________3. __________________________________________________________________________________4. __________________________________________________________________________________5. __________________________________________________________________________________Have your symptoms affected your ability to work/attend school? YES ____ NO _____If your best level of daily functioning is 100%, what has been your average level of functioning over the past month?0%10%20%30%40%50%60%70%80%90%100%PAST MEDICAL HISTORYHave you been diagnosed with any of the following conditions? (Check if yes)__ Postural orthostatic tachycardia syndrome (POTS)__ Vasovagal/neurocardiogenic syncope__ Migraine headache__ Small fiber neuropathy__ Chiari malformation__ Hydrocephalus__ Lyme disease__ Irritable bowel syndrome (IBS)__ Infectious mononucleosis__ Gastroparesis__ Celiac disease__ Median arcuate ligament syndrome (MALS)__ Small intestinal bacterial overgrowth (SIBO)__ Mast cell activation syndrome (MCAS)__ Ehlers-Danlos syndrome (EDS)__ Cerebrospinal fluid (CSF) leak syndrome__ Panic attack OR anxiety__ Motion sickness__ Attention-deficit/hyperactivity disorder (ADD/ADHD)__ Fibromyalgia__ Pelvic congestion syndrome (PCS)__ Polycystic ovarian syndrome (PCOS)__ Antiphospholipid syndrome (APS)PAST SURGICAL HISTORYHave you ever had the following surgeries/procedures? (Check if yes and provide date and location if known)__ Brain surgery: _______________________________________________________________________ Spinal surgery: _______________________________________________________________________ Spinal tap OR epidural injection: _________________________________________________________ Root canal: __________________________________________________________________________ Joint surgery: ________________________________________________________________________ Appendectomy: ______________________________________________________________________ Cholecystectomy: ____________________________________________________________________ Gastric bypass surgery: ______________________________________________________________Surgical complications (Please describe if you had any complications with the above surgeries):________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SOCIAL HISTORYPlease answer the following questions to the best of your ability. (If yes, please describe)What city/state do you live in? ___________________________________________________________What is your occupation? _______________________________________________________________What is your current marital status? _______________________________________________________Do you have children? _________________________________________________________________Do you smoke or vape? ________________________________________________________________Do you use marijuana? _________________________________________________________________Do you/have you used any other drugs? ___________________________________________________Do you consume alcohol? ______________________________________________________________Do you consume coffee/caffeinated beverages? _____________________________________________FAMILY HISTORYDo any of your family members have history of the following conditions? (Check if yes and list who)__ Dysautonomia (POTS or Ehlers-Danlos syndrome): __________________________________________ Autoimmune diseases (Lupus, multiple sclerosis, Rheumatoid arthritis, Sjogren’s syndrome): ______________________________________________________________________________________ Connective tissue disorders (Ehlers-Danlos syndrome, Marfan’s syndrome): ______________________________________________________________________________________ Sudden cardiac death: _________________________________________________________________ Aortic aneurysm: _____________________________________________________________________ Deep vein thrombosis OR pulmonary embolism: __________________________________________FLUID AND SALT INTAKEPlease answer the following questions to the best of your ability. (If yes, please describe)How much fluid do you drink daily (in oz or liters)? (A standard water bottle is ~16oz) ________________What type of drinks do you consume regularly? ______________________________________________Do you add salt to your food regularly? ____________________________________________________Do you use any salt tablets? _____________________________________________________________Are you following a specific diet currently? __________________________________________________EXERCISEPlease answer the following questions to the best of your ability. (If yes, please describe)Do you exercise on a regular basis, and if yes, how many minutes/hours weekly? ______________________________________________________________________________What type of exercises do you perform? _____________________________________________Does exercise make your symptoms worse? __________________________________________MEDICATIONSHave you ever tried or been prescribed any of the following medications? (Check if yes)__ Beta blockers (propranolol, atenolol, metoprolol, pindolol, Bystolic)__ Florinef (fludrocortisone)__ Midodrine__ Northera (droxidopa)__ Mestinon (pyridostigmine)__ DDAVP (desmopressin)__ Corlanor (ivabradine)__ Clonidine OR methyldopa OR Tenex (guanfacine)__ Carbidopa/levodopa__ Theophylline__ Stimulants (Ritalin, Adderall, Strattera, Concerta, Vyvanse, Focalin)__ Provigil (modafinil) OR Nuvigil (armodafinil)__SSRIs (Prozac, Zoloft, Paxil, Celexa, Lexapro)__ SNRIs (Effexor, Cymbalta, Pristiq, Savella)__ NDRI (Wellbutrin)__ TCA (Elavil, Pamelor, Doxepin)__ Benzodiazepines (Valium, Klonopin, Ativan)__ Sandostatin (octreotide)__ Norpace (disopyramide)__ Gabapentin OR Lyrica__ H1 blockers (Zyrtec, Allegra, Claritin, ketotifen, Benadryl, Xyzal)__ H2 blockers (Zantac, Pepcid, Tagamet)__ Cyproheptadine__ Cromolyn sodium__ Xolair (omalizumab)__ Gleevec (imatinib)__ Quercetin__ Rituxan (rituximab)__ Coenzyme Q10__ Magnesium__ Probiotics__ Birth control pills__ Scopolamine patch__ IV fluids__ CBD oil/cream__ MarijuanaALLERGIESDo you have any of the following allergies? (Check if yes, and please describe)__ Medication allergies: __________________________________________________________________ Food allergies: _______________________________________________________________________ Environmental allergies: _______________________________________________________________ Metal allergies: _____________________________________________________________________SPECIALISTSHave you been seen by any of the following specialists regarding your symptoms? (Check if yes)__ Cardiologist OR electrophysiologist__ Neurologist__ Rheumatologist__ Gastroenterologist__ Allergist OR immunologist__ Endocrinologist__ Gynecologist__ Psychiatrist__ Ear, nose, and throat (ENT) specialist__ Other: ____________________________________________________________________________DIAGNOSTIC TESTINGHave you undergone any of the following diagnostic testing? (Check if yes)__ Echocardiogram__ Stress test__ Tilt table test__ Heart monitor__ Autonomic function testing__ CT scan of the brain__ MRI of the brain__ MRI of the spine__ Electromyography (EMG) OR nerve conduction velocity (NCV)__ Skin biopsy for small fiber neuropathy__ Lumbar puncture__ Electroencephalogram (EEG)__ Upper OR lower endoscopy__ Abdominal ultrasound__ Sleep study__ Genetic testing__ Others: ___________________________________________________________________________CURRENT SYMPTOMSDo you currently have any of the following symptoms? (Check if yes)Dysautonomia__ Lightheadedness/dizziness upon standing or walking__ Syncope (passing out)__ Blurred vision__ Photosensitivity (light sensitivity)__ Palpitations (racing or skipping heartbeat)__ Chest pain__ Fatigue (Circle one: MILD MODERATE SEVERE)__ Exercise intolerance__ Heat intolerance__ Cold intolerance__ Excessive sweating__ Muscle twitches or cramps__ Body shaking__ Tremors__ Brain fog and/or memory loss__ Hoarseness of voice__ Ringing in the ears__ Excessive thirst__ Decreased appetite__ Decreased sense of smellNeurological__ Headache Location: ________________________Frequency: ______________________Severity: ________________________Relationship to posture: ______________ Tingling or numbness of the upper or lower extremities__ PainLocation: ________________________Severity: __________________________ Balance issues__ Double vision__ Seizures or convulsionsSleep__ Trouble falling asleep__ Frequently waking up in the middle of the night__ Vivid dreams and/or nightmares__ Snoring during sleep__ Racing heart during sleepHow many hours of restful sleep do you have nightly? ________________________________________How many hours do you nap during the daytime? ____________________________________________Pulmonary__ Shortness of breath__ Chronic cough__ Episodes of wheezing without any known history of asthma__ Nasal/sinus congestion without upper respiratory infectionMusculoskeletal__ Recurrent joint pain in 2+ joints for >3months__ Recurrent joint dislocation__ Frequent spontaneous popping of joints (subluxation)__ Double-jointed__ Dental crowding before braces__ Neck pain__ FallsSkin__ Flushing (face/neck turns red and/or warm spontaneously)__ Unexplained rashes that come and go__ Easy bruising__ Anaphylaxis or severe allergic reaction__ Unexplained episodes of swelling in arms and/or legs__ Recurrent drenching night sweats__ Soft or velvety skin__ Stretchy skin__ Stretch marks__ Skin hernia__ Thin “cigarette paper” scars__ Varicose veins__ Hair loss__ Dry mouth__ Dry eyes__ Trouble wearing contacts__ Raynaud’s phenomenon (fingers and/or toes turn blue/white in cold)Gastrointestinal__ Nausea and/or vomiting__ Diarrhea__ Constipation__ Abdominal cramps and/or pain__ Gastritis or ulcers or heart burn__ Abdominal bloating__ Feeling full quickly after eating__ Difficulty swallowing or choking__ Weight loss__ Bad breathGenitourinary__ Bladder issues (not related to UTI)__ Urinary frequency__ Urinary incontinence__ Urinary retention__ Pelvic pain__ Heavy menstruation__ Irregular menstrual cycles__ Retrograde ejaculation__ Uterine prolapse__ History of miscarriage, pre-eclampsia, or HELLP syndrome ................
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