Patient Intake Form

  • If you are being seen for symptoms of racing heart, dizziness, palpitations or chronic fatigue / brian fog, please answer these two questionnaires:
  • Compass 31 questionnaire
  • Once completed, calculate the score by hitting the Calculate button at the bottom of the page.
  • 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.
For best experience, we recommend completing the Patient Intake Form on a desktop computer.

The upload portal will only display on a desktop or laptop. If that option is not available to you, please come 30 minutes earlier to complete the forms.

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