Orthostatic Symptoms Tracking Form
Use this form to record orthostatic symptoms, triggers, and context over time. All responses help monitor symptom patterns and potential contributing factors.
Date and time of symptom occurrence
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
What symptoms did you experience?
*
Dizziness
Lightheadedness
Fainting (syncope)
Nausea
Blurred vision
Headache
Other
Symptom severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
How long did the symptoms last? (minutes)
*
What activity were you doing before symptoms started?
*
Please Select
Standing up from sitting
Standing up from lying down
Walking
Exercising
Showering
Other
Were you changing position when symptoms began?
*
Yes
No
Did you notice any triggers?
Heat exposure
Dehydration
Prolonged standing
Emotional stress
Other
How hydrated were you before symptoms?
Well hydrated
Somewhat hydrated
Dehydrated
Did you take any medication before symptoms?
Yes
No
Not sure
Additional notes or context
Submit
Should be Empty: