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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