COMPASS 31

COMPASS 31
Name

First NameLast Name
Date

MonthDayYear
Date
Treatment Status
Number of weeks on treatment blanks
1. In the past year, have you ever felt faint, dizzy, "goofy", or had difficultythinking soon after standing up from a sitting or lying position?

YesNo (if you marked No, please skip to question 5)
2. When standing up, how frequently do you get these feelings or symptoms?

RarelyOccasionallyFrequentlyAlmost Always
3. How would you rate the severity of these feelings or symptoms?

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

Gotten much worseGotten somewhat worseStayed about the sameGotten somewhat betterGotten much betterCompletely gone
5. In the past year, have you ever noticed color changes in your skin, such as red, white, or purple?

YesNo (if you marked No, please skip to question 8)
6. What parts of your body are affected by these color changes? (Check all that apply)

HandsFeet
7. Are these changes in your skin color:

Getting much worseGetting somewhat worseStaying about the sameGetting somewhat betterGetting much betterCompletely gone
8. In the past 5 years, what changes, if any, have occurred in your general body sweating?

I sweat much more than I used toI sweat somewhat more than I used toI haven't noticed any changes in my sweatingI sweat somewhat less than I used toI sweat much less than I used to
9. Do your eyes feel excessively dry?

YesNo
10. Does you mouth feel excessively dry?

YesNo
11. For the symptom of dry eyes or dry mouth that you have had for the longest period of time, is this symptom:

I have not had any of these symptomsGetting much worseGetting somewhat worseStaying about the sameGetting somewhat betterGetting much betterCompletely gone
12. 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 toI get full more quickly now than I used toI haven't noticed any changeI get full less quickly now than I used toI get full a lot less quickly now than I used to
13. In the past year, have you felt excessively full or persistently full (bloatedfeeling) after a meal?

NeverSometimesA lot of the time
14. In the past year, have you vomited after a meal?

NeverSometimesA lot of the time
15. In the past year, have you had a cramping or colick y abdominal pain?

NeverSometimesA lot of the time
16. In the past year, have you had any bouts of diarrhea?

YesNo (if you marked No, please skip to question 20)
17. How frequently does this occur?

RarelyOccasionallyFrequentlyConstantly
Time per month:
18. How severe are these bouts of diarrhea?

MildModerateSevere
19. Are your bouts of diarrhea getting:

Much worseSomewhat worseStaying the sameSomewhat betterMuch betterCompletely gone
20. In the past year, have you been constipated?

YesNo (if you marked No, please skip to question 24)
21. How frequently are you c onstipated?

RarelyOccasionallyFrequentlyConstantly
Time per month: blanks
22. How severe are these episodes of constipation?

MildModerateSevere
23. Is your constipation getting:

Much worseSomewhat worseStaying the sameSomewhat betterMuch betterCompletely gone
24. In the past year, have you ever lost control of your bladder function?

NeverOccasionallyFrequentlyConstantly
Time per month: blanks
25. In the past year, have you had diffic1Jlty passing urine?

NeverOccasionallyFrequentlyConstantly
Time per month: blanks
26. In the past year, have you had trouble completely emptying your bladder?

NeverOccasionallyFrequentlyConstantly
Time per month: blanks
27. In the past year, without sunglasses or tinted glasses, has bright lightbothered your eyes?

Never {if you marked Never, please skip to question 29)OccasionallyFrequentlyConstantly
28. How severe is this sensitivity to bright light?

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

Never (if you marked Never, please skip to question 31)OccasionallyFrequentlyConstantly
30. How severe is this focusing problem?

MildModerateSevere
31. Is the most troublesome symptom with your eyes (i.e. sensitivity to bright light or trouble focusing) getting:

I have not had any of these symptomsMuch worseSomewhat worseStaying about the sameSomewhat betterMuch betterCompletely gone
Sletten DM, Suarez GA, Low PA, Mandrekar J, Singer W. COMPASS 31: a refined and abbreviated Composite
Autonomic Symptom Score. Mayo Clin Proc. 2012 Dec;87(12):1196-201. doi: 10.1016/j.mayocp.2012.10.013.
PMID: 23218087; PMCID: PMC3541923.
Should be Empty: