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DYSAUTONOMIANEW PATIENT QUESTIONNAIRE DR. SCHOFIELDDate: Patient Name: Date of Birth: University of Colorado Medical records GENERALNoIMMUNOe records No CESIF yes please explain: No CESIF yes please

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Step 1: Gather all necessary information and medical records related to your dysautonomia.

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Step 2: Familiarize yourself with the specific form or questionnaire you need to fill out.

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Step 3: Start by filling out the basic personal information section, including your name, age, and contact details.

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Step 4: Provide a detailed medical history, including any previous diagnoses, treatments, and medications.

05

Step 5: Describe your specific symptoms and how they affect your daily life.

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Step 6: Provide information about any current treatments or therapies you are undergoing for dysautonomia.

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Step 7: If required, provide information about any additional medical professionals involved in your care, such as specialists or therapists.

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Step 9: Sign and date the form as required.

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Step 10: Submit the completed form to the relevant medical professionals or organizations responsible.

Who needs dysautonomia?

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Individuals who experience symptoms of dysautonomia.

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People who have been diagnosed with dysautonomia by a healthcare professional.

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Individuals seeking disability accommodations or support services due to dysautonomia.

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Patients who want to participate in dysautonomia research studies or clinical trials.

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Family members or caregivers of individuals with dysautonomia who need to understand the condition better.

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What is dysautonomia?

Dysautonomia is a disorder of the autonomic nervous system.

Who is required to file dysautonomia?

Patients diagnosed with dysautonomia are required to file.

How to fill out dysautonomia?

Dysautonomia can be filled out by providing medical history and symptoms to a healthcare provider.

What is the purpose of dysautonomia?

The purpose of dysautonomia is to track and manage symptoms related to autonomic nervous system dysfunction.

What information must be reported on dysautonomia?

Information such as medical history, symptoms, and treatment plans must be reported on dysautonomia.

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