Orthostatic Intolerance Assessment Form
Please complete this assessment to help us understand your symptoms, their impact, and any previous steps taken regarding orthostatic intolerance.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Female
Male
Non-binary
Prefer not to say
Other
How often do you experience symptoms of orthostatic intolerance (e.g., dizziness, lightheadedness, fainting) when standing up?
*
Never
Rarely
Sometimes
Often
Always
Please rate the severity of your symptoms when they occur.
*
1
2
3
4
5
Which of the following triggers seem to bring on your symptoms? (Select all that apply)
*
Standing up quickly
Prolonged standing
Heat exposure
Dehydration
After meals
Other
How much do your symptoms interfere with your daily activities?
*
Not at all
1
2
3
4
Severely
5
1 is Not at all, 5 is Severely
Please indicate which symptoms you experience and how frequently.
*
Rows
Never
Rarely
Sometimes
Often
Dizziness
1
2
3
4
Lightheadedness
5
6
7
8
Fainting
9
10
11
12
Palpitations
13
14
15
16
Nausea
17
18
19
20
Have you previously been evaluated by a healthcare provider for these symptoms?
*
Yes
No
Please list any treatments or management strategies you have tried (e.g., increased fluids, medications, compression stockings).
Submit Assessment
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