TIA Symptom Questionnaire
Please complete this form to help assess symptoms and risk factors related to a Transient Ischemic Attack (TIA).
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Email
*
example@example.com
Date and Time of Symptom Onset
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Which of the following symptoms did you experience? (Select all that apply)
*
Sudden weakness or numbness (face, arm, or leg)
Sudden difficulty speaking or understanding speech
Sudden vision changes (loss, double vision)
Sudden loss of balance or coordination
Sudden severe headache with no known cause
Other
How long did your symptoms last?
*
Less than 10 minutes
10–59 minutes
1–24 hours
More than 24 hours
Have your symptoms completely resolved?
*
Yes
No
Do you have any of the following risk factors? (Select all that apply)
*
High blood pressure (hypertension)
Diabetes
High cholesterol
Atrial fibrillation
Smoking
Family history of stroke/TIA
None of the above
Please rate the severity of your symptoms at their worst:
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Have you previously experienced similar symptoms?
*
Yes
No
Additional information or comments
Submit Questionnaire
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