Takotsubo Story Template

Please include any related pre-existing illness or stresses and any social details that you would like to share, such as fitness levels, job, family, etc.

Please supply a summary of events leading up to the episode. Describe the actual trigger (if known) Describe the symptoms Details of contact to emergency services/assistance.

Please supply a summary of how you were treated in hospital and any tests that you had such as coronary angiogram, MRI, echocardiogram, CT, etc) Describe any in-hospital complications Please list discharge medications. Please describe any referrals to health services and follow up care.

Please describe your recovery, any on-going symptoms, representations to ED. Please describe follow up care and tests. Please discuss any subsequent illnesses or conditions that developed after TTS.

Please include any other information that you would like to share or that you think is relevant.