Composite Autonomic Symptom Score – COMPASS 31 – Form

 

In this post I link to the Fillable PDF of the Composite Autonomic Symptom Score – COMPASS 31.

And here is the form:

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

1 Yes
2 No (if you marked No, please skip to question 5)

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

1 Rarely
2 Occasionally
3 Frequently
4 Almost Always

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

1 Mild
2 Moderate
3 Severe

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

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

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

1 Yes
2 No (if you marked No, please skip to question 8)

6. What parts of your body are affected by these color changes? (Check all thatapply)

1 Hands
2 Feet

7. Are these changes in your skin color:

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

Composite Autonomic Symptom Score – COMPASS 31
Name: Date:

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

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

9. Do your eyes feel excessively dry?

1 Yes
2 No

10. Does you mouth feel excessively dry?

1 Yes
2 No

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

1 I have not had any of these symptoms
2 Getting much worse
3 Getting somewhat worse
4 Staying about the same
5 Getting somewhat better
6 Getting much better
7 Completely gone

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

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

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

1 Never
2 Sometimes
3 A lot of the time

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

1 Never
2 Sometimes
3 A lot of the time1

15. In the past year, have you had acramping or colicky abdominal pain?

1 Never
2 Sometimes
3 A lot of the time

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

1 Yes
2 No (if you marked No, please skip to question 20)

17. How frequently does this occur?

1 Rarely
2 Occasionally
3 Frequently
4 Constantly

18. How severe are these bouts of diarrhea?

1 Mild
2 Moderate
3 Severe

19. Are your bouts of diarrhea getting:

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

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

1 Yes
2 No (if you marked No, please skip to question 24)

21. How frequently are you constipated?

1 Rarely
2 Occasionally
3 Frequently
4 Constantly

22. How severe are these episodes of constipation?

1 Mild
2 Moderate                      times per month:____
3 Severe

23. Is your constipation getting:

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

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

1 Never
2 Occasionally
3 Frequently
4 Constantly

25. In the past year, have you had diffic1Jlty passing urine?

1 Never
2 Occasionally
3 Frequently
4 Constantly

26. In the past year, have you had trouble completelyemptying your bladder?

1 Never
2 Occasionally
3 Frequently
4 Constantly

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

1 Never {if you marked Never, please skip to question 29)
2 Occasionally
3 Frequently
4 Constantly

28. How severe is this sensitivity to bright light?

1 Mild
2 Moderate
3 Severe

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

1 Never (if you marked Never, please skip to question 31)
2 Occasionally
3 Frequently
4 Constantly

30. How severe is this focusing problem?

1 Mild
2 Moderate                      times per month:____
3 Severe

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.

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