This Patient Questionnaire is offered as a helpful tool for you, the patient, to take with you to your doctor's appointment. It is common for dizzy patients to have problems with memory and concentration. By filling out this questionnaire before your visit, it will allow you to take the time to be as precise and thorough as you can and will help your doctor in evaluating your symptoms.
NAME:
___ DIZZINESS
___ IMBALANCE
___ HEARING PROBLEM
Date Symptoms Started:
Please explain in detail any injuries to head or ears, or illnesses that could be possible reasons for symptoms: (example; car accident)
Exposures:
___ Loud noise
___ Industrial Chemicals
Specific Symptoms that you have:
| Symptoms |
Constant
|
Attacks
|
| ___ Spinning |
___
|
___
|
| ___ Tumbling |
___
|
___
|
| ___ Tilting |
___
|
___
|
| ___ Rocking |
___
|
___
|
| ___ Swimmingness |
___
|
___
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| ___ Light-Headedness |
___
|
___
|
| ___ Nausea |
___
|
___
|
| ___ Vomiting |
___
|
___
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| ___ Double, Blurred or Jumping Vision |
___
|
___
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| ___ Headaches |
___
|
___
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| ___ Ear Pain |
___
|
___
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| ___ Noises in the Ear |
___
|
___
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| ___ Memory Problems |
___
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___
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| ___ Unable to Concentrate |
___
|
___
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| ___ Tingling around the mouth |
___
|
___
|
If symptoms come in attacks:
How Often?
How Long Do They Last?
Do you have any warning that an attack is about to begin?
Are your Symptoms brought on or affected by?
___ Changes in position of the head or body (example; bending over forward, turning over in bed)
Explain:
___ Standing Up
___ Looking Up
___ Rapid head movements
___ Reading
___ Darkness
___ Airplane, boat or car travel
___ Underwater Diving
___ Elevators
___ Patterned carpets or floors
___ Loud noises
___ Bright Lights
___ Coughing, blowing the nose, sneezing
___ Straining, Lifting, Exercise
___ Department Stores, Grocery Stores
___ Foods, Salt intake, eating or not eating
___ Heat, Hot showers
___ Time of Day, Seasonal Changes
___ Stress
___ Alcohol, Drugs (Prescription or otherwise)
___ Menstrual Periods ( If applicable)
Others:
Ear Problems:
Have you ever had:
___ Abnormal noise in Right Ear
___ Abnormal noise in Left Ear
___ Hissing ___ Right ___Left
___ Ringing ___ Right ___Left
___ Musical ___ Right ___Left
___ Sensitivity ___ Right ___Left
___ Fullness or Pressure ___ Right ___Left
___ Pain in Ear ___ Right ___Left
___ Hearing Loss ___ Right ___Left
Are any of the previous symptoms aggravated or increased when/if you suffer
an attack of vertigo or dizziness? If so, which ones?
What are your current medications and dosage?
What other medications have you tried for this problem?
Have you had any of the tests listed below?
BAER (evoked potentials for acoustic neuroma)
Date _____________ Abnormal?___________
ENG Caloric test (water in ear)
Date _____________ Abnormal?___________
ECOG (evoked potentials for Meniere's syndrome)
Date _____________ Abnormal?___________
Hearing test (Audiogram)
Date _____________ Abnormal?___________
Posturography test (balance test machine)
Date _____________ Abnormal?___________
Rotatory Chair test (spinning test)
Date _____________ Abnormal?___________
Lumbar puncture (spinal fluid examination)
Date _____________ Abnormal?___________
EEG (Brain Wave test for seizures)
Date _____________ Abnormal?___________
Recent general medical checkup?
Date _____________ Abnormal?___________
Recent general blood tests
Date _____________ Abnormal?___________
X-RAYS
Date _____________ Abnormal?___________
MRI and/or CT scan of the head
Date _____________ Abnormal?___________
Angiogram of the head
Date _____________ Abnormal?___________
Sinus X-rays
Date _____________ Abnormal?___________
Neck X-rays
Date _____________ Abnormal?___________
Chest X-ray
Date _____________ Abnormal?___________
Do you give your permission to contact your doctor(s) for records related to the
reason for this appointment?
___YES
___NO