Survey

1) What is your most bothersome symptom?

Anxiety
Chest pain
Palpitations
Panic attacks
Dizziness
Fatigue
Shortness of breath

2) What type of doctor do you see?

Cardiologist
Family/General practitioner
Other
None

3) Do you feel your doctor is supportive?

Very
Somewhat
Not at all
N/A

4) What is your gender?

Female
Male

5) How often do you exercise?

Regularly
Often
Sometimes
Rarely
Never

6) What type of exercise?

Aerobics/Videos
Walking
Jogging
Weight training
Some/All of the above
None

7) At what age were you diagnosed?

0-12
13-18
19-25
26-35
36-50
50Plus

8) How has MVP(S) affected your life?

Drastically
Somewhat
Not at all

9) Are you...

Overweight
Underweight
Average

10) Do you use medications to control symptoms?

Anti-anxiety
Beta blockers
Homeopathic/Natural remedies
None

11) Do you have relatives that have MVP(S)?

Parent
Sibling
Other blood relative(s)
Some/All of the above
None

12) What medication do you use to premed before dental visits?

Erythromycin
Amoxicillin
Zithromax
Clindamycin
Other
None

13) For those women who've had children: Did your major symptoms start...

Before becoming pregnant?
During pregnancy?
Within the first year of childbirth?
During/After a subsequent pregnancy?
Other

14) Do you smoke?

Yes
No

15) Do you have frequent urinary tract infections (Cystitis)?

Yes
No

16) How many amalgam (silver) fillings do you have?

None
1-3
4-6
7 or more

17) Have you been diagnosed with endometriosis?

Yes
No


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