Patient Intake Form | Dr. Cynthia

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Patient Intake Form

If your consultation is for evaluation of POTS / Dysautonomia / COVID long hauler, please complete the Compass 31 questionnaire
Once completed, calculate score
Print questionnaire and result page to PDF and save on computer
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Fill out the Malmo POT score questionnaire. Results will automatically submit to Dr. Cynthia.
Both these subjective autonomic assessments along with objective autonomic testing will guide Dr. Cynthia to the most appropriate diagnosis and treatment plan.

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Upload the PDF patient intake form

Accepted file types: pdf, Max. file size: 32 MB.

Please attach (JPG) images of front and back of insurance cards, and any pertinent medical records (PDF only).

Upload the COMPASS 31 questionnaire results (if applicable)

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Accepted file types: jpg, pdf, Max. file size: 32 MB, Max. files: 10.

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Holistic Cardiologist

Dr. Cynthia Thaik, MD, serves the Los Angeles area, including Burbank, Valencia, Santa Clarita, Glendale & Pasadena

Cardiology Office

2211 W. Magnolia Blvd, Ste 140
Burbank, CA 91506
Phone: (818) 842-1410
FAX: (818) 842-1408
9AM – 4PM (Mon – Fri)

Satellite Office

1110 S. Robertson Blvd. #6
Los Angeles, CA 90035
Cardiology – Virtual visits only
Ideal Protein Weight Loss – in person by appointment only

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Malmo POT Score (MAPS score)

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Date*

Name*

First Last

Date of Birth*

Email*

This questionnaire concerns symptoms related to postural orthostatic tachycardia syndrome (POTS). It will help us to evaluate how affected you are by symptoms originating from this syndrome. We kindly ask you to fill in this questionnaire as thoroughly as possible.

Please circle the number on following scale that corresponds to your average symptoms for the past week. You should only answer once per question. If you haven’t experienced symptoms described below, circle zero (0).

There are 12 questions.

No symptoms (0) Pronounced symptoms (10)

1. Dizziness in upright position or while standing up*

2. Dizziness, feeling that you are going to faint*

3. Palpitations, high pulse, or feeling heart beating irregularly*

4. Difficult breathing/dyspnoea, both at effort and rest*

5. Chest pain*

6. Headache*

7. Concentration difficulties and/or problems with thinking*

8. Muscle pain*

9. Nausea*

10. Gastrointestinal problems (stomach-ache, diarrhoea, constipation)*

11. Abnormal tiredness that persists after rest*

12. Insomnia*

In a study of 62 POTS patients versus 50 healthy controls, “the optimal cut-off value to discriminate between POTS and healthy controls was a total MAPS score of ≥42, yielding excellent sensitivity (97%; 95% confidence interval [CI] 0.89–0.99) and specificity (98%; 95% CI 0.89–0.99).”

For more information on POTS, visit www.potsfoundation.org.au and

https://www.ausdoc.com.au/therapy-update/postural-orthostatic-tachycardiasyndrome/

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