Takotsubo Wall Survey

It is difficult to know how many people experience Takotsubo syndrome (TTS) as most cases are not reported in scientific journals. Please consider filling in the details on this form so that we may build a ‘wall’ with details of people who have experienced TTS to give researchers and clinicians a better idea of how many people around the world do experience TTS. Your anonymous details provided in the form below will be added to the wall.

  • Please state the month and year that TTS occurred in the format __/____
  • Please write the initials of your first name and your last name. Only your initials are required.
  • What was your age at the time that you were diagnosed with TTS?
  • If this is your first episode of TTS, please select 'first'. If not, please select the episode of diagnosed TTS that this information refers to. If you have had more than one diagnosed episode of TTS, please fill in a form for each episode.
  • Please state in 25 words or less what event caused you TTS. Some examples: argument with neighbour, childbirth; chemotherapy (type); earthquake; death of spouse; exercise (type); heat stress etc.