COMPASS Autonomic Nervous System Scoring Test

Autonomic Symptom Profile

Answer every question by darkening the appropriate oval. If you are unsure about how to answer a question, please give the best answer you can. Please darken the corresponding oval completely.

1. In the past year, have you ever felt faint, dizzy or ‘goofy’ or had difficulty thinking soon after standing up from a sitting or lying position?

O 1 Yes If you marked Yes go to question 2.
O 2 No If you marked No go to question 5.

1. When standing up, how frequently do you get these feelings or symptoms?

O 1 Rarely
O 2 Occasionally
O 3 Frequently
O 4 Almost always

1. How would you rate the severity of these feelings or symptoms?

O 1 Mild
O 2 Moderate
O 3 Severe

1. In the past year, have these feelings or symptoms that you have experienced:

O 1 Got much worse
O 2 Got somewhat worse
O 3 Stayed about the same.
O 4 Got somewhat better
O 5 Got much better
O 6 Completely gone.

1. In the past year, how often have you ended up fainting soon after standing up from a sitting or lying position?

O 0 Never
O 1 Once
O 2 Twice
O 3 Three times
O 4 Four times
O 5 Five or more times

Please rate the average severity you have experienced in the past year for each of the following symptoms:

Never had Mild Moderate Severe

1. Rapid or increased heart rate (palpitations)? O 1 O 2 O 3 O 4

1. Sick to your stomach (nausea) or vomiting? O 1 O 2 O 3 O 4

1. A spinning or swimming sensation? O 1 O 2 O 3 O 4

1. Dizziness? O 1 O 2 O 3 O 4

1. Blurred vision? O 1 O 2 O 3 O 4

1. Feeling of weakness? O 1 O 2 O 3 O 4

1. Feeling shaky or shaking sensation? O 1 O 2 O 3 O 4

1. Feeling anxious or nervous? O 1 O 2 O 3 O 4

1. Turning pale? O 1 O 2 O 3 O 4

1. Clammy feeling to your skin? O 1 O 2 O 3 O 4

In the past year, have you ever felt faint, dizzy, or ‘goofy’ or had difficulty thinking:

1. …soon after a meal? 1 Yes O 2 No

1. …after standing for a long time? O 1 Yes O 2 No

1. …during or soon after physical activity or exercise? O 1 Yes O 2 No

1. …during or soon after being in a hot bath, shower, tub or sauna? O 1 Yes O 2 No

In the past year, have you fainted:

1. …while passing urine? O 1 Yes O 2 No

1. …while coughing? O 1 Yes O 2 No

1. …while pressing on your neck? O 1 Yes O 2 No

1. …before a public speech? O 1 Yes O 2 No

1. …any other time? O 1 Yes O 2 No

In the past 5 years how would you rate the amount of trouble, if any you have had:

None Some A lot Constant

1. …with paralysis in parts of your face? O 1 O 2 O 3 O 4

1. …with attacks of uncontrollable movements O 1 O 2 O 3 O4

of your arms and legs?

1. …with attacks in which you couldn’t control O 1 O 2 O 3 O4

your speech?

1. In the past year, have you ever noticed colour changes in your skin, such as red, white or purple?

O 1 Yes If yes, continue with question 19. O 2 No If no, go to question 29.

What colour skin changes have occurred (check all that apply)

1. O My skin turns red.

1. O My skin turns white.

1. O My skin turns purple.

1. O Other, please specify …………………………………………………

What parts of your body are affected by these colour changes? (check all that apply)

1. O My hands.

1. O My feet.

1. O Other parts, please specify ……………………………………………

1. O Entire body

1. For how long have you been experiencing these changes in skin color?

O 1 Less than 2 months
O 2 3-6 months
O 3 7-12 months
O 4 13 months to 5 years
O 5 More than 5 years
O 6 As long as I can remember

1. Are these changes in skin color:

O 1 Getting much worse
O 2 Getting somewhat worse
O 3 Staying about the same
O 4 Getting somewhat better
O 5 Getting much better
O 6 Completely gone

1. In the past 5 years, what changes, if any, have occurred in your general body sweating?

O 1 I sweat much more than I used to.
O 2 I sweat somewhat more than I used to.
O 3 I haven’t noticed any changes in my sweating.
O 4 I sweat somewhat less than I used to.
O 5 I sweat much less than I used to.

1. In the past 5 years, what changes, if any, have occurred in the amount your feet sweat?

O 1 They sweat much more than they used to.
O 2 They sweat somewhat more than they used to.
O 3 I haven’t noticed any changes.
O 4 They sweat somewhat less than they used to.
O 5 They sweat much less than they used to.

1. In the past 5 years, what changes, if any, have occurred in facial sweating after eating spicy foods?

O 1 I sweat much more than I used to.
O 2 I sweat somewhat more than I used to.
O 3 I haven’t noticed any changes in my sweating.
O 4 I sweat somewhat less than I used to.
O 5 I sweat much less than I used to.
O 6 I avoid eating spicy foods because I sweat so much.
O 7 I avoid eating spicy foods for other reasons.

In the past 5 years, what changes, if any, have occurred in your ability to tolerate heat during a hot day, strenuous work or exercise, hot bath or shower, hot tub or sauna? (check all that apply).

1. O I now get more overheated.

1. O I now get dizzy.

1. O I now get short of breath.

1. O Other changes, please specify …………………………………………..

1. O No change.

1. Do your eyes feel excessively dry? O 1 Yes O 2 No

1. Does your mouth feel excessively dry? O 1 Yes O 2 No

1. In the past year, have you noticed any changes in how quickly you get full when eating a meal?

O 1 I get full a lot more quickly now than I used to.
O 2 I get full more quickly now than I used to.
O 3 I haven’t noticed any change.
O 4 I get full less quickly now than I used to.
O 5 I get full a lot less quickly now than I used to.

1. In the past year, have you felt excessively full or persistently full (bloated feeling) after a meal?

O 1 Never O 2 Sometimes O 3 A lot of the time

1. In the past year, have you felt like you had a persistent upset stomach (nausea)?

O 1 Never O 2 Sometimes O 3 A lot of the time

1. In the past year, have you vomited after a meal?

O 1 Never O 2 Sometimes O 3 A lot of the time

1. In the past year, have you had a cramping or colicky abdominal pain?

O 1 Never O 2 Sometimes O 3 A lot of the time

1. In the past year, have you had any bouts of diarrhea?

O 1 Yes If yes continue with question 45 O 2 No If no go to question 48

1. How frequently does this occur?

O 1 Rarely O 2 Occasionally
O 3 Frequently ………..times per month O 4 Constantly

1. How severe are these bouts of diarrhea?

O 1 Mild O 2 Moderate O 3 Severe

1. Are your bouts of diarrhea getting:

O 1 Much worse
O 2 Somewhat worse
O 3 Staying the same
O 4 Somewhat better
O 5 Much better
O 6 Completely gone

1. In the past year, have you been constipated?

O 1 Yes If Yes continue below with question 49 O 2 No If No go to question 52.

1. How frequently are you constipated?

O 1 Rarely O 2 Occasionally
O 3 Frequently ………..times per month O 4 Constantly

1. How severe are these bouts of constipation?

O 1 Mild O 2 Moderate O 3 Severe

1. Is your constipation getting:

O 1 Much worse
O 2 Somewhat worse
O 3 Staying the same
O 4 Somewhat better
O 5 Much better
O 6 Completely gone

1. 52 In the past 5 years, how would you rate the amount of trouble, if any, you have had with difficulty swallowing?

O 1 No trouble
O 2 Some trouble
O 3 A lot of trouble
O 4 Constant trouble

1. In the past 5 years, how would you rate the amount of trouble, if any, you have had with everything you eat tasting the same.

O 1 No trouble
O 2 Some trouble
O 3 A lot of trouble
O 4 Constant trouble

Have you ever in your life:

1. Been nauseated or vomited O 1 Yes O 2 No

1. Had a bout of diarrhea O 1 Yes O 2 No

1. Lost your appetite for at least part of the day O 1 Yes O 2 No

1. Felt discomfort or pain in the pit of the stomach O 1 Yes O 2 No

• In the past year, have you ever leaked urine or lost control of your bladder function?

O 1 Never O 2 Occasionally
O 3 Frequently ………..times per month O 4 Constantly

• In the past, have you had difficulty passing urine?

O 1 Never O 2 Occasionally
O 3 Frequently ………..times per month O 4 Constantly

• In the past year, have you had trouble completely emptying your bladder?

O 1 Never O 2 Occasionally
O 3 Frequently ………..times per month O 4 Constantly

1. In the past year, without sunglasses or tinted glasses, has bright light bothered your eyes?

O 1 Never O 2 Occasionally
O 3 Frequently O 4 Constantly

1. How severe is the sensitivity to light?

O 1 Mild O 2 Moderate O 3 Severe

1. In the past year, have you had trouble focusing your eyes?

O 1 Never O 2 Occasionally
O 3 Frequently O 4 Constantly

1. How severe is this focusing problem?

O 1 Mild O 2 Moderate O 3 Severe

• In the past year, has the same degree of light seemed:

O 1 Excessively dimmer O 2 Much dimmer
O 3 About the same O 4 Much brighter
O 5 Excessively brighter

• How long have you had troublesome eye symptoms?

O 0 I don’t have any of these symptoms
O 1 Less than 3 months
O 2 3 to 6 months
O 3 7 to 12 months
O 4 13 months to 5 years
O 5 More than 5 years
O 6 As long as I can remember

1. Is this most troublesome symptom with your eyes getting:

O 0 I don’t have any of these symptoms
O 1 Much worse
O 2 Somewhat worse
O 3 Staying the same
O 4 Somewhat better
O 5 Much better
O 6 Completely gone

1. In the past year, have you ever noticed or been told that while sleeping you stop breathing for several seconds?

O 1 Yes O 2 No

1. In the past year, have you ever noticed or been told that while sleeping you snore loudly?

O 1 Yes O 2 No

Have you ever been told you have or been diagnosed as having:

1. Narcolepsy O 1 Yes O 2 No O 3 Don’t know

1. Obstructive sleep apnea O 1 Yes O 2 No O 3 Don’t know

1. Abnormal or disordered sleep patterns O 1 Yes O 2 No O 3 Don’t know

1. Currently, how refreshing and restorative is your sleep

O 1 Not at all restorative – derive no benefit
O 2 Some slight restorative value
O 3 Restorative, but not adequate
O 4 Relatively satisfactory
O 5 Very satisfactory – feel completely refreshed

1. Compared with a year ago, how would you rate your own sleep over the last month?

O 1 Last month was much worse than a year ago
O 2 Last month was slightly worse than a year ago
O 3 Last month was about the same as a year ago
O 4 Last month was slightly better than a year ago
O 5 Last month was much better than a year ago

1. Have you ever in your adult life had difficulty getting to sleep O 1 Yes O 2 No

or staying asleep once you were asleep?

1. In the past year, have you ever noticed or been told that O 1 Yes O 2 No

during the day you sometimes breathe very loudly (e.g. croup)?

1. In the past 5 years, how would you rate the amount of trouble, if any you have had with over sensitive hearing?

O 1 None O 2 Some O 3 A lot O 4 Constant

1. Have you ever in your adult life had difficulty keeping your mind on your job or task?

O 1 Yes O 2 No



THE FOLOWING QUESTIONS ARE APPLICABLE TO MALE SUBJECTS ONLY.

1. Are you able to have a full erection?

O 1 Never, under any circumstances
O 2 Much less frequently than in the past
O 3 Somewhat less frequently than in the past
O 4 The same, or more frequently, than in the past

Which of the following statements apply to your situation? (Fill in all that apply)

1. O 1 My ability to have intercourse has not changed.

1. O 1 I have erections but am unable to have intercourse.

1. O 1 I can have intercourse only some of the time.

1. O 1 My erections are definitely impaired.

1. O 1 I am able to have intercourse, but am unable to ejaculate

1. O 1 I have ‘dry’ orgasms and afterward my urine looks milky.

1. O 1 I have been unable to have erections or they have been impaired since I started taking a medication called ………………………………………………………….

1. O 1 Other situation, please describe …………………………………………..

1. O 1 None of the above apply.

1. How long have you had difficulty with erectile function?

O 0 I do not have this difficulty
O 1 Less than 3 months
O 2 3 to 6 months
O 3 7 to 12 months
O 4 13 months to 5 years
O 5 More than 5 years
O 6 As long as I can remember

1. Is this difficulty getting:

O 0 I do not have difficulty
O 1 Much worse
O 2 Somewhat worse
O 3 Staying the same
O 4 Somewhat better
O 5 Much better
O 6 Completely gone

Find how to score the test here