This survey is the Compass 31.  It is a well established self-report instrument used by health care providers to learn about the health of the nervous system.  Please read each question carefully and respond  thoughtfully.  

Please enter your ID and Zip/Postal Code at the end of the survey, along with today's date.

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

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

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

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

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

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* 6. What parts of your body are affected by these color changes?   Check all that apply.

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* 7. Have the changes in skin color:

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

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* 9. Do your eyes feel excessively dry?

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* 10. Does your mouth feel excessively dry?

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* 11. For the symptoms of dry eyes and dry mouth that you have had for the longest time, it this symptom:

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

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

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

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

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* 16. In the past year have you had any bouts of diarrhea?

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* 17. How frequently does this occur? 

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* 18. How severe are the bouts of diarrhea?

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* 19. Have the bouts of diarrhea:

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* 20. In the past year have you had been constipated?

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* 21. How frequently are you constipated?

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* 22. How severe are these episodes of constipation?

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* 23. Has your constipation:

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* 24. In the past year, have you ever lost control of your bladder function? 

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* 25. In the past year, have you had difficulty passing urine?

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* 26. In the past year, have you had trouble completely emptying your bladder?

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* 27. In the past year, without sunglasses, has bright light bothered your eyes?

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* 28. How severe is this sensitivity to bright light?

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

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* 30. How severe is the focusing problem?

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* 31. Has the most troublesome symptom with your eyes (i.e. sensitivity to bright lights or trouble focusing)

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* 32. Please enter today's date. 

Date

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* 33. Please enter your ID Code

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* 34. Please enter your zip/postal code. 

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