Malmö POTS Score Assessment (MAPS)

Instructions

This questionnaire concerns symptoms related to postural orthostatic tachycardia syndrome (POTS). It will help us to evaluate how affected you are by symptoms originating from this syndrome.

Please select the number on the following scale that corresponds to your average symptoms for the past week. You should only answer once per question. If you haven’t experienced symptoms described below, select zero (0).

Scale: 0 = No symptoms, 10 = Pronounced symptoms

Patient Name *

Date of Birth *

Assessment Date *

Physician Name

Dizziness in upright position or while standing up *

effort both difficulties

Dizziness, feeling that you are going to faint *

Palpitations, high pulse, or feeling heart beating irregularly *

Difficult breathing/dyspnoea, both at effort and rest *

Chest pain *

Headache *

Concentration difficulties and/or problems with thinking *

Muscle pain *

Nausea *

Gastrointestinal problems (stomach-ache, diarrhoea, constipation) *

Abnormal tiredness that persists after rest *

Insomnia *

Contact:

For all bookings and referrals –
Tel: 08 6162 1615 (Option 1)
Fax : 08 9382 2637
Email: pots@perthpaediatrics.com.au