COMPASS-31
Autonomic Aseessment
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
COMPASS-31 Score
In the past year, have you ever felt faint, dizzy, "goofy", or had difficulty thinking soon after standing up from a sitting or lying position?
*
Yes
No
When standing up, how frequently do you get these feelings or symptoms?
Rarely
Occasionally
Frequently
Almost Always
How would you rate the severity of these feelings or symptoms?
Mild
Moderate
Severe
In the past year, have these feelings or symptoms that you have experienced
Gotten much worse
Gotten somewhat worse
Stayed about the same
Gotten somewhat better
Gotten much better
Have completely gone away
In the past year, have you ever noticed color changes in your skin, such as red, white, or purple?
Yes
No
What parts of your body are affected by these color changes? (Check All That Apply)
Hands
Feet
These changes in your skin color have:
Gotten much worse
Gotten somewhat worse
Stayed about the same
Gotten somewhat better
Gotten much better
Completely gone away
In the past 5 years, what changes, if any, have occurred in your general body sweating?
I sweat much more than I used to
I sweat somewhat more than I used to
I haven't noticed any changes in my sweating
I sweat somewhat less than I used to
I sweat much less than I used to
Do your eyes feel excessively dry?
Yes
No
Does your mouth feel excessively dry?
Yes
No
For the feeling of dry eyes OR dry mouth that you've had for the longest period of time, this symptom has:
Gotten much worse
Gotten somewhat worse
Stayed about the same
Gotten somewhat better
Gotten much better
Completely gone away
I have not had any of these symptoms
In the past year, have you noticed any changes in how quickly you get full when eating a meal?
I get full a lot more quickly now than I used to
I get full more quickly now than I used to
I haven’t noticed any change
I get full less quickly now than I used to
I get full a lot less quickly now than I used to
In the past year, have you felt excessively full or persistently full (bloated feeling) after a meal?
Never
Sometimes
A lot of the time
In the past year, have you vomited after a meal?
Never
Sometimes
A lot of the time
In the past year, have you had a cramping or colicky (sharp, localized) abdominal pain?
Never
Sometimes
A lot of the time
In the past year, have you had any bouts of diarrhea?
Yes
No
How frequently does the diarrhea occur?
Rarely
Occasionally
Frequently (multiple times per month)
Constantly
How severe are these bouts of diarrhea?
Mild
Moderate
Severe
Your bouts of diarrhea are getting:
Much worse
Somewhat worse
Staying the same
Somewhat better
Much better
Completely gone
In the past year, have you been constipated?
Yes
No
How frequently does the constipation occur?
Rarely
Occasionally
Frequently (multiple times per month)
Constantly
How severe are these bouts of constipation?
Mild
Moderate
Severe
Your bouts of constipation are getting:
Much worse
Somewhat worse
Staying the same
Somewhat better
Much better
Completely gone
In the past year, have you ever lost control of your bladder function?
Never
Occasionally
Frequently (multiple times per month)
Constantly
In the past year, have you ever had difficulty emptying your bladder?
Never
Occasionally
Frequently (multiple times per month)
Constantly
In the past year, without sunglasses or tinted glasses, has bright light bothered your eyes?
Never
Occasionally
Frequently (multiple times per month)
Constantly
How severe is this sensitivity to light?
Mild
Moderate
Severe
In the past year, have you had trouble focusing your eyes?
Never
Occasionally
Frequently (multiple times per month)
Constantly
How severe is this focusing problem?
Mild
Moderate
Severe
The most troublesome symptom with your eyes (i.e. sensitivity to bright light or trouble focusing) is getting:
Much worse
Somewhat worse
Staying the same
Somewhat better
Much better
Completely gone
Submit
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