logo for integrative cardiologist Dr. Cynthia Thaik

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
  • Upload attachment

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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.
You must request for an APPOINTMENT before uploading information and records. 

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Name*
Accepted file types: pdf, Max. file size: 32 MB.
Upload the COMPASS 31 questionnaire results (if applicable)
Drop files here or
Accepted file types: jpg, pdf, Max. file size: 32 MB, Max. files: 10.
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    This field is for validation purposes and should be left unchanged.

    Malmo POT Score (MAPS score)

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    Name*
    Date of Birth*

    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)

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    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/

    This field is for validation purposes and should be left unchanged.