testform

Name of Individual Seeking Consultation: *

Patient - First and Last Name: *

Relation to the Patient: *
For myselfFor a family memberFor a friendOther

How did you hear about us/referred by? *

Patient Age: *

Phone Number: *

Your Email: *

State: *

Country:
United StatesCanadaMexico

Diagnosis Given to the Patient: *
POTSDysautonomia DisorderNo formal diagnosis, but suspected POTSOther:

Please check off any symptoms that apply to the patient: *
Headaches/ MigrainesTachycardia (fast heartbeat)NauseaDizziness/ LightheadednessFatigueFainting or Near Fainting EpisodesSeizuresBrain FogTunnel Vision (narrowed eyesight)Thermoregulation (overheating/ cold sensitivity)High/ Low Blood PressureGastrointestinal IssuesInsomniaOther

Additional History *

Throughout the week, what timings are you available for your consultation? *
MorningsAfternoonsAll day

Do you consider yourself a high-achiever? *

On a scale of 1-10, with 10 being highly motivated, how motivated are you to engage in a program to help alleviate your POTS symptoms without drugs? *
12345678910

Do you feel you have a support system in place? Check any of the following that apply to you: *
Parent(s)GrandparentsSibling(s)SpouseOther family ChurchCounselorSignificant Other

Have you had COVID-19? *
YesNo

Have you had the vaccine and/or the vaccine booster shots? *
YesNo

Did you experience onset of POTS symptoms (or) were your existing POTS symptoms exacerpated after COVID or after the vaccine and/or booster shots? *
YesNo

If the program is out of network with your health insurance/self-paid or you can get partial reimbursement would you still consider enrollment into the program to help alleviate your symptoms for better quality of life, even if you needed to set up an out-of-pocket payment arrangement? *
YesNo