Dysautonomia Assessment Please enable JavaScript in your browser to complete this form.Date / TimeDateTimeSelect All Symptoms That You HaveLightheadednessFeeling FaintFatigueMental CloudinessDifficulty finding WordsShort-term Memory LossSensitive Light, Sound, TouchPins & Needles Arms/LegsNumbness Hands & FeetPain Neck & ShouldersHeadacheTension HeadacheNausea & VomitingDifficulty StandingChest PainPalpitationsShort of BreathHypermobility in JointsDepressionAnxietyProfuse SweatingInability to SweatDry MouthCold Hands-FeetDimmed VisionRinging EarsCan't Maintain TemperatureUnstable Blood PressureUnstable PulseAbnormal TemperaturePlease select ALL that you are experiencingPulseUsing a pulse oximeter please record your pulse in beats per minute. TemperaturePlease use a thermometer to record your current temperatureBlood Pressure: Diastolic Please use a blood pressure cuff to measure your B.P. sitting, at rest. Diastolic is the lower recordingBlood Pressure: SystolicPlease use a blood pressure cuff to measure your B.P. sitting, at rest. Systolic is the higher recordingSubmit