Your Fainting History
Take Fainting to Heart
Fainting History
Complete this fainting history form and be sure to share it with your healthcare team. This information will provide them with a more complete understanding of your syncope experience.
- I had my first unexplained fainting spell on _________(date).
- I have had _____ fainting spells in the past two years.
- Before I fainted, I was _______________________________.
- I drive.
True
False - I am worried about fainting while driving.
True
False - My job puts me at risk for fainting.
True
False - I am worried about fainting at work.
True
False - I have been monitored or tested to find the cause of my fainting.
True List tests___________________________________
False - I have heart palpitations or other heart irregularities before or after fainting.
True
False - My family history includes undiagnosed fainting or sudden cardiac death.
True
False - I am receiving treatment for fainting spells but the treatment is not helping.
True List Treatments__________________________________
False