POTS Self-Assessment Questionnaire — Wellness Station Exercise Physiology

POTS / OI (Postural Orthostatic Tachycardia Syndrome / Orthostatic Intolerance)

This POTS / OI (Postural Orthostatic Tachycardia Syndrome / Orthostatic Intolerance) Questionnaire will approximately take 5 minutes to complete. Once the form is submitted, we will send you the results via email within seven business days.

Name

First Name

Last Name

Other additional information

Diagnosis, Current or Previous Physical Activity, Past treatments, Medication.

Do you frequently experience shortness of breath?

Do you experience frequent feelings of extreme dizziness and fatigue?

Do you ever feel anxious at night?

How frequently do you experience dizziness and shortness of breath?

Have you been experiencing gastric problems within the past week?

How frequently do you encounter instances of elevated heart rates?

Do you experience frequent feelings of extreme dizziness and fatigue?

Do you suffer from severe migraines?

Do you become dehydrated quickly?

Do you encounter vision loss while showering or face difficulties with showering in general?

Does your Heart Rate increases by 30 or more within 10 minutes after standing?

Our POTS progam includes the following:

Phase 1: Assessment and Patient Education

Activity Pacing
Goal Setting
Postural testing and exercise tolerance testing
Trigger Mapping / Management
Stress and Anxiety Management
Mindfulness
Fluid intake monitoring
Sleep Hygiene

Phase 2: Activity and Symptom Diary Analysis and Formulation of Strategies.

Phase 3: Strategy fine-tuning

Phase 4: Establishment of asymptomatic exercise baseline.

Phase 5: Self-management

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