Scheduling Form March 30, 2017

In order to expedite the scheduling process, please complete this online form. Answering as many of the questions as possible will help us to better understand the autonomic nature of your condition. Once your form is received, one of our medical staff will get in touch with you to review your case and advise you on how to proceed.

Allergies:

 Google Yahoo/Bing Doctor Referral Friend/Family Email Blog Other

Current Symptoms:

1. Manifestations occurring after changing position:
In the past year, have you frequently (at least once a week) experienced one or more symptoms, such as palpitations, dizziness, blurred vision or feeling of weakness, after standing up from a sitting or lying down position?
 No Yes (Mild) Yes (Moderate) Yes (Severe)

2. Skin manifestations (at least one abnormal finding):
In the past year, have you noticed frequent (at least once a week) changes in skin color, such as red, white or purple? Cutaneous abnormalities at examination?
 No Yes (Mild) Yes (Moderate) Yes (Severe)

3. Thermic dysfunctions (at least one abnormal finding):
In the past year have you frequently (at least once a week) experienced hot or cold limbs? Thermic modifications found by the examiner? Thermal perception abnormalities comparing hot and cold stimulations?
 No Yes (Mild) Yes (Moderate) Yes (Severe)

4. Sphincter dysfunction (at least one abnormal finding):
In the past year, have you frequently (at least once a month) lost control of your bladder function? In the past year, have you experienced difficulty in completely emptying your bladder? In the past year, have you frequently (at least once a month) been constipated?
 No Yes (Mild) Yes (Moderate) Yes (Severe)

5. Sexual dysfunction (at least one abnormal finding):
In the past year, have you frequently (at least once a month) had problems with ejaculation? In the past year, have you experienced difficulty in ejaculation?
 No Yes (Mild) Yes (Moderate) Yes (Severe)

6. Gastroparesis (at least one abnormal finding):
In the past year, have you frequently (at least once a month) experienced nausea and vomiting after a meal? In the past year, have you experienced feeling full early when eating? In the past year, have you frequently (at least once a month) had abdominal bloating and/or dis- comfort after a meal?
 No Yes (Mild) Yes (Moderate) Yes (Severe)

We Respect Your Privacy.

By submitting this form, you agree to our Terms of Service.

We Believe:
  • michael-a-arata-headshot
  • Restoring quality of life to patients with chronic illness is a priority. - Michael Arata, MD