Today M-D-Y
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Today M-D-Y
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Date of diagnosis of broken heart/takotsubo syndrome
Today M-D-Y
Medical record number at that hospital, if known
Symptoms on presentation (check all that apply)
Chest pain
Palpitations
Shortness of breath
Shortness of breath with exertion
Decreased exercise tolerance
Nausea
Vomiting
Lightheadedness
Loss of consciousness
Other
None
Unknown
Please detail in your own words what brought you to the hospital at that time
Was there an emotional or physical trigger that you can identify?
Yes No Other Unknown
Emotional trigger
Physical trigger
Both
For emotional trigger, please specify
Anger Financial/job related Grief/sickness/loss of a loved one Interpersonal conflict Panic or fear Other Unknown
Please specify other emotional trigger
For physical trigger, please specify
Illness High intensity exercise Surgery Other Unknown
Please specify other physical trigger
If you would like to tell us more, please describe
Did you have a second episode of broken heart syndrome?
Yes No
Date of diagnosis of broken heart/takotsubo syndrome
Today M-D-Y
Medical record number at that hospital, if known
Symptoms on presentation (check all that apply)
Chest pain
Palpitations
Shortness of breath
Shortness of breath with exertion
Decreased exercise tolerance
Nausea
Vomiting
Lightheadedness
Loss of consciousness
Other
None
Unknown
Please detail in your own words what brought you to the hospital at that time
Was there an emotional or physical trigger that you can identify?
Yes No Other Unknown
Emotional trigger
Physical trigger
Both
For emotional trigger, please specify
Anger Financial/job related Grief/sickness/loss of a loved one Interpersonal conflict Panic or fear Other Unknown
Please specify other emotional trigger
For physical trigger, please specify
Illness High intensity exercise Surgery Other Unknown
Please specify other physical trigger
If you would like to tell us more, please describe
Did you have a third episode of broken heart syndrome?
Yes No
Date of diagnosis of broken heart/takotsubo syndrome
Today M-D-Y
Medical record number at that hospital, if known
Symptoms on presentation (check all that apply)
Chest pain
Palpitations
Shortness of breath
Shortness of breath with exertion
Decreased exercise tolerance
Nausea
Vomiting
Lightheadedness
Loss of consciousness
Other
None
Unknown
Please detail in your own words what brought you to the hospital at that time
Was there an emotional or physical trigger that you can identify?
Yes No Other Unknown
Emotional trigger
Physical trigger
Both
For emotional trigger, please specify
Anger Financial/job related Grief/sickness/loss of a loved one Interpersonal conflict Panic or fear Other Unknown
Please specify other emotional trigger
For physical trigger, please specify
Illness High intensity exercise Surgery Other Unknown
Please specify other physical trigger
If you would like to tell us more, please describe
Did you have a fourth episode of broken heart syndrome?
Yes No
Date of diagnosis of broken heart/takotsubo syndrome
Today M-D-Y
Medical record number at that hospital, if known
Symptoms on presentation (check all that apply)
Chest pain
Palpitations
Shortness of breath
Shortness of breath with exertion
Decreased exercise tolerance
Nausea
Vomiting
Lightheadedness
Loss of consciousness
Other
None
Unknown
Please detail in your own words what brought you to the hospital at that time
Was there an emotional or physical trigger that you can identify?
Yes No Other Unknown
Emotional trigger
Physical trigger
Both
For emotional trigger, please specify
Anger Financial/job related Grief/sickness/loss of a loved one Interpersonal conflict Panic or fear Other Unknown
Please specify other emotional trigger
For physical trigger, please specify
Illness High intensity exercise Surgery Other Unknown
Please specify other physical trigger
If you would like to tell us more, please describe
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