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Table 2 Self-administered patient questionnaire

From: Benefit of dual-chamber pacing with Closed Loop Stimulation in tilt-induced cardio-inhibitory reflex syncope (BIOSync trial): study protocol for a randomized controlled trial

1) Did you faint (losing consciousness partially or completely)? 0 No 1 Yes - date: (dd-mm-yyyy) __ __ - __ __ - __ __ __ __
2) If ‘yes’, 0 You completely lost consciousness? 1 You recognized having the premonitory symptoms of imminent loss of consciousness but they were not followed by complete loss of consciousness, i.e., pre-syncope?
If ‘yes’ only:
3) Was the episode characterized by a rapid onset, short duration and spontaneous complete recovery? 0 No 1 Yes
4) Have you realized that the episode was similar to those that you had before the pacemaker implantation? 0 No 1 Yes
5) Have you had time to stop and lie/sit down? 0 No 1 Yes
6) Was the event witnessed by other people? 0 No 1 Yes
7) Where did the event occur? 0 At home 1 Away from home
8) What were you doing immediately before the event? 0 I was standing 1 I was sitting 2 I was lying 3 I had just stood up
9) Please describe the situation: _____________________________________ _____________________________________ _____________________________________
10) Have you been injured due to the event? 0 No 1 Yes
11) Did you go to the emergency room due to the injuries? 0 No 1 Yes
12) Were you hospitalized due to the injuries? 0 No 1 Yes