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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:

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

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