BHC Research Inquiry

  • BHC Research Inquiry

    Please complete the following survey if you are interested in participating in a Research opportunity at Bateman Horne Center. Completion of this form means your information will be added to our Research Database for studies being conducted now or in the future.
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Are you able to attend in person visits in Salt Lake City, Utah?*

  • Please Note

    Completion of these forms does not guarantee enrollment into a study. The Bateman Horne Center (BHC) study team will review your submitted questionnaire and will contact you regarding next steps.

    Enrollment in the study does not constitute a medical diagnosis; it solely indicates that you meet the eligibility criteria for participation.

  • Orthostatic Hypotension Questionnaire (OHQ)

    Patient Instructions: We are interested in measuring the symptoms that occur because of your problem with low blood pressure (orthostatic intolerance) and the degree that those symptoms may interfere with your daily activity. It is important that we measure the symptoms that are due ONLY to your low blood pressure, and not something else (like diabetes or Parkinson's disease). Many people know which of their symptoms are due to low blood pressure. Some people who have recently developed problems with low blood pressure may not easily distinguish symptoms of low blood pressure from symptoms caused by other conditions. In general, symptoms of your low blood pressure problem will appear either upon standing or after you have been standing for some time and will usually improve if you sit down or lie down. Some patients even have symptoms when they are sitting which might improve after lying down. Some people have symptoms that improve only after sitting or lying down for quite some time.

  • Please answer the questions below keeping in mind that we want to know only about those symptoms that are from your problem with low blood pressure. 

  • OH Symptom Assessment (OHSA)

    Please tick the number on the scale that best rates how severe your symptoms from low blood pressure have been on the average over the past week. You should respond to every symptom. If you do not experience the symptoms, circle zero (0). YOU SHOULD RATE ONLY THE SYMPTOMS THAT ARE DUE TO YOUR LOW BLOOD PRESSURE PROBLEM.
  • Rows

  • OH Daily Activity Scale

    We are interested in how the low blood pressure symptoms that you experience affect daily life. Please rate each item by ticking the number that best represents how much on the average the activity has been interfered with over the past week by the low blood pressure you have experienced. If you cannot do the activity for reasons other than low blood pressure, please check the box at the right.
  • Rows

  • IOM ME/CFS Criteria

  • How FREQUENTLY do you experience the following symptoms?

  • A substantial reduction or impairment in the ability to engage in pre-illness levels of occupational, educational, social, or personal activities, that persists for more than 6 months and is accompanied by fatigue, which is often profound, is of new of definite onset, is not the result of ongoing excessive exertion, and is not substantially alleviated by rest.*
  • Worsening of symptoms with physical or cognitive exertion*
  • Worsening of symptoms with physical or cognitive exertion*
  • Insomnia or waking unrefreshed*
  • Cognitive impairment or brain fog*
  • Orthostatic intolerance or worsening of symptoms when upright*

  • How SEVERE are the following symptoms?

  • A substantial reduction or impairment in the ability to engage in pre-illness levels of occupational, educational, social, or personal activities, that persists for more than 6 months and is accompanied by fatigue, which is often profound, is of new of definite onset, is not the result of ongoing excessive exertion, and is not substantially alleviated by rest.*
  • Worsening of symptoms with physical or cognitive exertion*
  • Worsening of symptoms with physical or cognitive exertion*
  • Insomnia or waking unrefreshed*
  • Cognitive impairment or brain fog*
  • Orthostatic intolerance or worsening of symptoms when upright*

  • Good Day/Bad Day Questionnaire

  • Communicating impaired function can be challenging for people ME/CFS, FM, OI, and Long COVID. In addition, clinicians often lack the time and tools to fully grasp the extent of impairment. BHC developed a simple questionnaire that helps patients to communicate the frequency, severity, and nature of their activity limitations.

    Estimating the number of better (GOOD) versus worse (BAD) days and listing specific examples communicates the range of function.

    Hours of Upright Activity (HUA), or time spent with feet on the floor (sitting, standing, walking) versus time spent with feet elevated in 24 hours, takes a little thinking but clearly communicates tolerance for upright activity.

  • Good Days

    While there may never be a true “good” day with chronic illness, there are “better” or more functional days. Indicate your hours of upright activity and ability to perform tasks on good or better illness days.

  • For the following, consider:

    • Activities of daily living include things like dressing, bathing, preparing food, etc.
    • Cognitive processing (reading, writing, answering text messages/emails, holding conversations, etc.)
    • What other areas/aspects of daily living are affected by your illness?

  • Bad Days

    Indicate your hours of upright activity and the level of function you experience on bad or worsened illness days.

  • For the following, consider:

    • Activities of daily living include things like dressing, bathing, preparing food, etc.
    • Cognitive processing (reading, writing, answering text messages/emails, holding conversations, etc.)
    • What other areas/aspects of daily living are affected by your illness?
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