Questionnaire

ORTHOSTATIC HYPOTENSION AMONG PATIENTS AGED ABOVE 65

ADMITTED TO MEDICAL WARDS IN A TERTIARY CARE HOSPITAL, SRI
LANKA
BHT no:

Serial no:

Age:

Gender:

Area of residence:

Educational status:

Ethnicity:

Height:

BMI:

Weight:
Occupation:

Monthly income:

No of household members:

Social support:

Smoking:

Alcohol consumption:

Medical history
Co- morbidities
Diabetes:

Hypertension:

Hyperlipidemia:

Asthma:

COPD:

Neurological problems:

Others (please specify):

Medications:

Symptoms of orthostatic hypotension

Please rate the following on how severe your symptoms from low blood pressure have been on
average over the past week. Please respond to every symptom. If you do not experience the
symptom mark it as '0'.
1. Dizziness, light headedness, faintishness
0

10

2. Problems with vision; blurring, seeing spots, tunnel vision

0

10

10

10

10

10

3. Weakness
0

4. Fatigue
0

5. Trouble concentrating
0

6. Head, neck discomfort

0

Effects of orthostatic symptoms

Please rate each item from 0-10; where 0 = no interference and 10 = complete interference. If the
inability was due to any other cause mark it appropriately.
1. Standing for a short period of time (<15mins)
0

10

Any other cause

10

Any other cause

10

Any other cause

10

Any other cause

2. Standing for a long period of time (>30mins)

0

3. Walking for a short period of time (<15mins)

0

4. Walking for a long period of time (>30mins)

0

Assessment of falls
Circle the appropriate response as yes or no.
1) History of falls (within the past year):
1

A fall is defined as unintentionally coming to rest on the ground, floor or other lower level
with or without injury.
Yes

How many times? ________

No

1. A near fall is a slip or trip but you were able to catch yourself. Have you experienced a near
fall?
Yes

How many times? ________

No

2. Have you visited an emergency department, your family doctor or another health
professional as a result of a fall in the past year?
Yes

How many times? ________

No

3. If you fell, would you need help to get up from off the ground?
Yes

No

2) Postural hypotension:
1

Have you ever fallen because of sudden, unexpected fainting or blackouts?

Yes

No

1. Have you been told that you have low blood pressure?
Yes

No

2. Do you ever get dizzy when getting out of bed, or standing up from a chair?
Yes

No

3) Gait, balance, mobility:

1

Do you feel unsteady when you walk, or notice any balance difficulties during day to day
tasks like walking, moving from sit to stand, or changing direction?
Yes

No

1. Do you use a walking aid or has anyone advised you that you should use one?
Yes

No

2. Do you require assistance for day to day tasks such as bathing, showering, preparing meals
or other personal care?
Yes

No

4) Visual acuity:
1. Do you have vision problems such as blurriness, difficulty seeing to the side, different
depths, distances or that you are sensitive to changing light?
Yes

No

2. Was your last visit to the optometrist/ophthalmologist over a year or two ago?
Yes
5) Other neurological and/or cognitive impairments:

No

1. Do you have any neurological conditions such as multiple sclerosis, Parkinsons disease, or
history of stroke?
Yes

No

2. Do you notice that you have problems with your memory? (more than normal, more than
other people your age do)
Yes

No

3. Does your family or friends say that you have problems with your memory?
Yes

No

4. Do you have trouble completing familiar tasks? E.g. writing a check, finding your way in a
familiar mall/store.
Yes

No

5. Do you have problems with bowel and/or bladder control?

Yes

No

6) Muscle Strength:
1. Do you have any conditions that have caused muscle weakness in your legs? I.e. arthritis,
recent joint surgery, or any other health conditions that have altered your ability to do day to
day activities?
Yes

No

2. Has your leg or legs ever given out on you when climbing stairs, walking, or
unexpectedly?
Yes

No

3. Do you feel you have leg or ankle weakness or that you tire easily when you walk?
Yes

No

7) Heart Rate and rhythm/cardiac impairments:

1. Do you have any cardiac conditions such as hypertension, arrhythmia, or a recent heart
attack?
Yes

No

2. Have you been told that your heart rate is too high or too low?
Yes

No

3. Have you noticed any difficulty with getting short of breath easily with day to day activities
or you have to stop and rest frequently during the day?
Yes

No

8) Feet and Footwear:

1. Do you have any numbness or loss of sensation in your feet?
Yes

No

2. Do you have difficulty wearing shoes due to arthritis or any other conditions?
Yes

No

3. Do you commonly wear slippers without backs when in the house?

Yes

No

Blood pressure measurements

On admission
Blood pressure (Supine)

SBP________________

Blood pressure (Erect)

1min SBP________________

2min

DBP______________
SBP________________

3min

DBP______________

DBP______________

SBP________________

DBP______________

After 3 days
Blood pressure (Supine)

SBP________________

Blood pressure (Erect)

1min SBP________________

2min

DBP______________
SBP________________

3min

DBP______________

DBP______________

SBP________________

DBP______________