This questionnaire helps your provider assess whether your symptoms may be related to Postural Orthostatic Tachycardia Syndrome (POTS) — a condition affecting how your body regulates heart rate and blood pressure when you stand up. Please answer all questions honestly. There are no right or wrong answers. Your responses will be reviewed by your clinician at your visit.
1
Core Orthostatic Symptoms
Do you experience any of the following?
Yes
No
Lightheadedness, dizziness, or feeling faint when you stand up
Heart racing or pounding when you stand up or shortly after
Symptoms that consistently get worse within 10 minutes of standing up
Symptoms that get better or go away when you lie back down
Near-fainting (feeling like you’re about to pass out) or actually fainting
Difficulty standing in lines, taking long showers, or being upright for long periods
2
Symptom Frequency
For each symptom below, select how often you experience it.
Symptom
Never
0
0
Rarely
1
1
Sometimes
2
2
Often
3
3
Daily
4
4
Palpitations or rapid heartbeat when standing
Lightheadedness or near-fainting
Profound fatigue or inability to exercise
Brain fog, poor concentration, or memory problems
Headaches, especially when upright
Nausea, bloating, or stomach discomfort
Vision graying out or blurring when you stand up
Shakiness, tremors, or weakness
Excessive sweating or feeling overheated
Poor, unrefreshing sleep or insomnia
Running total: 0 / 40
3
Other Symptoms & Conditions
Have you experienced or been diagnosed with any of the following?
Yes
No
Heart & Circulation
Chest tightness or pressure
Irregular heartbeat or skipped beats
Digestive
Frequent nausea, vomiting, or feeling full quickly
Irritable bowel symptoms (diarrhea, constipation, cramping)
Joints & Muscles
Very flexible joints, frequent sprains, or joints that dislocate easily
Widespread muscle or joint pain most days
Nervous System
Numbness, tingling, or burning sensations in hands/feet
Anxiety or feeling “wired” without a clear reason
Skin & Blood Flow
Legs or feet turn red, purple, or mottled when standing
Fingers or toes turn white or blue in the cold (Raynaud’s)
4
What Makes Your Symptoms Worse?
Do any of the following make your symptoms worse?
Yes
No
Heat, warm weather, or hot showers
Eating a large meal or high-carbohydrate food
Physical exercise or exertion
Your menstrual cycle (symptoms worse around your period)
Drinking extra water or salty foods seems to help your symptoms
Symptoms are worse in the morning than later in the day
Caffeine or alcohol noticeably makes things worse
5
Your Health History
Have you ever been diagnosed with any of the following?
Yes
No
Dysautonomia, orthostatic hypotension, or vasovagal syncope
Ehlers-Danlos Syndrome (EDS) or hypermobility spectrum disorder
Mast Cell Activation Syndrome (MCAS) or severe allergic reactions
Fibromyalgia, ME/CFS, or chronic fatigue syndrome
Autoimmune conditions (lupus, RA, Sjögren’s, Hashimoto’s, etc.)
Thyroid disease or diabetes
Family history of POTS, dysautonomia, or connective tissue disorder
6
At-Home Vital Signs
How to measure: Lie down and rest for at least 5 minutes. Take your heart rate and blood pressure while lying down, then stand up and immediately take them again at 1 minute, 3 minutes, and 5 minutes. Use a home blood pressure cuff with a heart rate display if possible. Write down each reading below.
Heart Rate (beats per minute)
Lying down
Standing 1 min
Standing 3 min
Standing 5 min
Blood Pressure (mmHg)
Lying down
Standing 1 min
Standing 3 min
Standing 5 min
Not required: If you don’t have a blood pressure cuff at home, skip the BP fields and just record your pulse. You can use a smartwatch, pulse oximeter, or manually count your heartbeats for 30 seconds and multiply by 2. Important: Stop standing if you feel faint and sit or lie down immediately.
Your responses will be securely sent to Ananda Integrative Medicine
