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CHARACTERISTICS OF DIZZINESS IS YOUR DIZZINESS ASSOCIATED WITH ANY OF THE FOLLOWING SENSATIONS? PLEASE READ THE ENTIRE LIST FIRST. THEN CIRCLE YES OR NO TO DESCRIBE YOUR FEELINGS MOST ACCURATELY
YES NO 1. Lightheadedness or swimming sensation in the head. YES NO 2. Blacking out or loss of consciousness. YES NO 3. Tendency to fall. YES NO 4. Objects spinning or turning around you. YES NO 5. Sensation that you are turning or spinning inside, with outside objects remaining stationary. YES NO 6. Loss of balance when walking in the light: Veering to the : Right? Left? YES NO 7. Loss of balance when walking in the dark: Veering to the : Right? Left? YES NO 8. Headache. YES NO 9. Nausea. YES NO 10.Vomiting. YES NO 11. Pressure in the head. YES NO 12. Tingling in the fingers or toes? YES NO 13. Tingling around the mouth?
TIME COURSE & AGGRAVATING FACTORS
1. When did your dizziness first occur? ___________________________ 2. How often do you become dizzy? _____________________________ 3. If in attacks, how long does an attack last? ______________________ YES NO 4. Do you have any warning that the attack is about to start? YES NO 5. Do they occur at any particular time of day or night? YES NO 6. Are you completely free of dizziness between attacks? YES NO 7. Does change of position make you dizzy? Which movements? _________________________________________________ YES NO 8. Do you become dizzy when rolling over in bed? To the Right? To the Left? YES NO 9. Do you know of any possible cause for your dizziness? If so What? ________________________________________________ 10. Do you know of anything that will: YES NO a. stop your dizziness or make it better? ________________________________ YES NO b. make your dizziness worse? _______________________________________ YES NO 11. Do you become dizzy when you bend your head forward? YES NO 12. Do you become dizzy when you bend your head backward? YES NO 13. Do you become dizzy when you cough? YES NO 14. Do you become dizzy when you sneeze? YES NO 15. Do you become dizzy when you have a bowel movement? 16. Can any of the following make your dizziness worse or precipitate an attack?
YES NO Fatigue? YES NO Exertion? YES NO Hunger? YES NO Menstrual Period? YES NO Stress? YES NO Emotional Upset? YES NO Alcohol? YES NO 17. Do you have any allergies? What? _________________________________________
ASSOCIATED OTOLOGIC SYMPTOMS Do you have any of the following symptoms? Please circle Yes or No and circle the ear involved, if appropriate.
YES NO 1. Dizziness. Describe dizziness _______________________________________________ YES NO 2. Difficulty in hearing? Both Ears Right Ear Left Ear YES NO 3. Does your hearing change with dizziness? If so how? _______________________________________________ YES NO 4. Do you have noise in your ears? Both Ears Right Ear Left Ear Describe the noise: _______________________________________________
YES NO 5. Does noise change with dizziness? If so how? ______________________________________________ YES NO 6. Do your ears have fullness or stuffiness? Both Ears Right Ear Left Ear YES NO 7. Do you have pain in your ears? Both Ears Right Ear Left Ear YES NO 8. Do you have discharge in your ears? Both Ears Right Ear Left Ear
ASSOCIATED NEUROLOGIS SYMPTOMS HAVE YOU EXPERIENCED ANY OF THE FOLLOWING SYMPTOMS? PLEASE CIRCLE YES OR NO AND CIRCLE IF CONSTANT OR IN EPISODES.
YES NO 1. Double Vision. Constant In Episodes YES NO 2. Blurred vision. Constant In Episodes YES NO 3. Blindness. Constant In Episodes YES NO 4. Numbness of the face or extremities. Constant In Episodes YES NO 5. Weakness in the arms or legs. Constant In Episodes YES NO 6. Clumsiness of the arms or legs. Constant In Episodes YES NO 7. Confusion or loss of consciousness. Constant In Episodes YES NO 8. Difficulty with speech. Constant In Episodes YES NO 9. Difficulty with swallowing. Constant In Episodes YES NO 10. Pain in the neck or shoulders. Constant In Episodes
PAST MEDICAL HISTORY
YES NO 1. Do you have a history or ear infections as a child? YES NO 2. Did you ever injure your head? When? ________________________________________ YES NO 3. Were you ever unconscious? When? ________________________________________ YES NO 4. Did you ever suffer from motion sickness before the age of 12? YES NO 5. Have you suffered from motion sickness in the last 10 years? YES NO 6. Do you take any medications regularly? What? ________________________________________ YES NO 7. Have you taken medications for dizziness? What? _____________________________ YES NO 8. Do you use tobacco of any kind? What? ___________ How often? ________________ YES NO 9. Does caffeine affect your dizziness? How? ___________________________________ YES NO 10. Does alcohol affect your dizziness? How? __________________________________ YES NO 11. Do you have a past medical history of Diabetes? YES NO Heart Disease? YES NO High Blood Pressure? YES NO Kidney disease? YES NO Thyroid disease? YES NO Migraine headache? YES NO 12. Do you have a family history of Ear Disease? Neurologic disease? Migraine headaches?
Thank you for taking the time to fill this out. Please return to the receptionist or give to the nurse.
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