Tilt Table Test Discharge Instructions Form
Please review and confirm your understanding of the instructions to follow after your Tilt Table Test.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Tilt Table Test
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Best phone number for follow-up
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address (for discharge summary)
example@example.com
Do you understand that you should rest and avoid strenuous activities for the next 24 hours?
*
Yes
No
Do you understand the importance of staying hydrated after the test?
*
Yes
No
Have you been informed about symptoms to watch for (such as dizziness, fainting, chest pain) and when to seek medical help?
*
Yes
No
Is someone available to accompany you home after the test?
*
Yes
No
Submit
Should be Empty: