STARS US

1. First Name*
2. Last Name*
3. Email Address*
4. Gender* -- Please select -- Male Female
5. Contact type * -- Please select -- Carer Charity Industry Patient Journalist
6. How did you hear about us? * -- Please select -- Event Email Friend Healthcare professional Mailing Poster Press Radio/TV Website

These details will help to inform, educate and raise awareness of syncope globally. Carers can complete on behalf of patients

1. Patients Date of Birth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
2. Diagnosis
3. Medical tests
   24-hr EKG monitor
   Blood pressure
   Blood test
   Echocardiogram
   Exercise Test
   EP Study
   12-Lead EKG
   7-14 Day EKG monitor
   EEG
   Implantable Cardiac Monitor
   Implantable Cardiac Monitor
   Pulse Check
   Tilt Table Test
   
4. Medical procedures
   No device or procedure
   Cardiac Resynchronisation Therapy-Implantable Cardiac Defibrillator (ICD)
   Cardiac Resynchronisation Therapy-Pacemaker
   Implantable Cardiac Defibrillator (ICD)
   Implantable Loop Recorder
   Pacemaker
   Subcutaneous Implantable Cardiac Defibrillator (S-ICD)
   
5. Medications for syncope
   No medications
   Beta blockers
   Ivabradine
   Not sure of medications
   Anti-Epileptic Drugs (AEDs)
   Fludrocortisone
   Midodrine
   Octreotide
   Other (please specify)
   
6. Ethnic origin