TDP Patient Survey First Name Last Name Address 1 Address 2 City * State/Province Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavat Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip Biological Sex * Female Male Phone Email 1. Have you been diagnosed with a form of dysautonomia (any disorder of the autonomic nervous system)? * Yes No
5. By whom was the dysautonomia diagnosis made? * A local doctor An autonomic specialst Other
6. Did anything happen which seemed to trigger or cause your dysautonomia? (viruses, trauma, surgery, etc.) * Yes No
8. In order, what are your top three most difficult symptoms from the list above? 9. Do your dysautonomia symptoms require the assistance of any medical aid or help (such as a cane, wheelchair, service dog, etc.) ? * Yes No
10. Have these symptoms impacted your ability to lead a normal life and do activities that most people do? * Yes No
11. Are you able to go to school or work? * Yes No
12. Do you require accommodations for school or work? * Yes No
17. Have you read all or part of The Dysautonomia Project book? * Yes No