Palpitations Evaluation Form
Please complete the Palpitations Evaluation Form to help us understand your symptoms and their impact. All questions are non-sensitive and designed for your comfort.
Full Name
*
First Name
Last Name
Age
*
When did you first notice palpitations?
*
 -
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
Rarely
How long does each episode of palpitations typically last?
*
Seconds
Minutes
Hours
Varies
What usually triggers your palpitations?
*
Exercise
Stress or anxiety
Caffeine
No clear trigger
Other
Do you experience any of the following symptoms with palpitations?
*
Dizziness
Shortness of breath
Chest discomfort
Fatigue
None of the above
On a scale of 1 to 10, how severe are your palpitations?
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Do palpitations interfere with your daily activities?
*
Not at all
Slightly
Moderately
Significantly
Please describe any additional details about your palpitations.
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