Table 2.
Self-administered patient questionnaire
| 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 |