Palpitations Symptom Checklist
Please complete this checklist to help assess your palpitations symptoms. Your responses will assist healthcare providers in understanding your experience.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
When did your palpitations first start?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How often do you experience palpitations?
*
Daily
Several times a week
Once a week
Less than once a week
How long do your palpitations typically last?
*
A few seconds
Less than 1 minute
1–5 minutes
More than 5 minutes
Please rate the severity of your palpitations.
*
Mild
1
2
3
4
Severe
5
1 is Mild, 5 is Severe
Which of the following symptoms do you experience along with palpitations? (Select all that apply)
Dizziness or lightheadedness
Shortness of breath
Chest discomfort or pain
Fainting or near-fainting
Sweating
None of the above
Other
Do you notice any specific triggers for your palpitations?
Exercise or physical activity
Stress or anxiety
Caffeine or energy drinks
Alcohol
Medications
No specific trigger
Other
How much do palpitations interfere with your daily activities?
*
Not at all
1
2
3
4
A lot
5
1 is Not at all, 5 is A lot
Do you have any of the following medical conditions? (Select all that apply)
High blood pressure
Heart disease
Thyroid disorder
Diabetes
None of the above
Other
Please list any medications or supplements you are currently taking.
Additional comments or information about your palpitations (optional)
Submit Checklist
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