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Dizziness Questionnaire 1/5
Please submit this questionnaire prior to your appointment
I accept the above
Patient’s Details:
Name:
(Required)
Address:
(Required)
DOB:
(Required)
Phone/Mobile:
(Required)
Gender:
(Required)
Female
Male
The following questions refer to your feeling of dizziness. Please fill in all the blanks.
Have you in the past, had an off balance/vertigo/dizzy symptom sensation?
(Required)
Yes
No
If so, please describe in your own words the off balance/vertigo/dizzy symptom sensation you experienced THEN without using the word “dizzy”. If there are more than one distinct type of sensation please describe both:
Please describe if any significant events which led up to THE VERY FIRST initial off balance/vertigo/dizzy symptom sensation ever experienced, even if was years ago (eg cold or flu symptoms, flight, head trauma):
Do you currrently have an off balance/vertigo/dizzy symptom sensation?
(Required)
Yes
No
If so, Please describe in your own words the off balance/vertigo/dizzy symptom sensation you CURRENTLY feel without using the word “dizzy”. If there are more than one distinct type of sensation please describe both:
Also, please describe if any significant events which led up to the CURRENT off balance/vertigo/dizzy symptom sensation you feel (eg cold or flu symptoms, flight, head trauma):
Please describe how long the symptoms lasted for and if symptoms changed:
Do you ever have any of the following sensations?
(Required)
Spinning in circles
Falling to one side
World spinning around you
None of the above
Dizziness Questionnaire 2/5
Please submit this questionnaire prior to your appointment
I accept the above
The following questions refer to typical dizzy spells. Select only those that apply and answer as appropriate.
Do your dizzy spells come in attacks?
(Required)
Yes
No
How often?
How long do/did the attacks last for? Seconds/minutes/hours/days/weeks/months/constant: If more than one type of dizziness describe both:
Date of first spell/attack?
Are you currently feeling dizzy?
(Required)
Yes
No
Are you free from dizziness between attacks?
(Required)
Yes
No
Are you dizzy or unsteady constantly?
(Required)
Yes
No
Do you get any warning the dizziness is about to start?
(Required)
Yes
No
What are the warning signs?
Are you dizzy at certain times of the day or night?
(Required)
Yes
No
If so which?
Did you take any medications (inc strong antibiotics, chemotherapy, quinine etc) prior to symptom onset?
(Required)
Yes
No
If yes what were they?
Did you have any cold or flu like symptoms prior to onset?
(Required)
Yes
No
Does your hearing change with an attack?
(Required)
Yes
No
Do you only get dizzy when you move?
(Required)
Yes
No
Are you dizzy mainly when you sit or stand up quickly?
(Required)
Yes
No
Are you dizzy when you look up, down or bend forward or backwards?
(Required)
Yes
No
If so which?
Are you dizzy if you roll over in bed?
(Required)
Yes
No
If so in the right or left side?
Are you dizzier in certain positions?
(Required)
Yes
No
Which position?
Are you nauseated during an attack?
(Required)
Yes
No
Are you dizzy even when lying down?
(Required)
Yes
No
Does closing your eyes make your dizziness worse?
(Required)
Yes
No
Are you better if you sit or lie perfectly still?
(Required)
Yes
No
Have you had a recent cold or flu preceding recent dizzy spells?
(Required)
Yes
No
Have you had fullness, pressure, or ringing in your ears?
(Required)
Yes
No
Have you had pain or discharge in your ear of recent onset?
(Required)
Yes
No
Do you have a loss of balance when walking in dark?
(Required)
Yes
No
If so veering to the right or left?
Do you have a loss of balance when walking in the light?
(Required)
Yes
No
If so veering to the right or left?
Do loud sounds make you dizzy?
(Required)
Yes
No
Do you get dizzy when you cough, sneeze, blow nose, bowel movement or other?
(Required)
Yes
No
If so which?
Are your symptoms exacerbated or initiated when in upright posture eg. standing or sitting?
(Required)
Yes
No
If yes, please explain
Are your symptoms exacerbated or initiated when in motion eg. walking, driving, flying etc?
(Required)
Yes
No
If yes, please explain
Are your symptoms exacerbated or initiated when not in motion but visual stimuli gives impression of moving (eg. sitting in car and cars beside you move giving sensation of movement)?
(Required)
Yes
No
If yes, please explain
Are your symptoms exacerbated or initiated with seeing moving objects or complex visual patterns (eg. computer/TV screens with moving images, patterned carpets, clothes or pictures)?
(Required)
Yes
No
If yes, please explain
Any other comments about your dizziness you feel is pertinent?
Dizziness Questionnaire 3/5
Please submit this questionnaire prior to your appointment
I accept the above
The following refer to other sensations you may have. Select only those that apply and answer as appropriate.
Do you black out or faint when dizzy?
(Required)
Yes
No
Have you had:
(Required)
Severe or recurrent headaches or migraines?
Light and/or sound sensitivity leading up to or during your headaches or dizziness/vertigo?
Visual Auras (eg. lines, spots, squiggles) leading up to or during your headaches or dizziness/vertigo?
Any double or blurry vision?
None of the above
Select All
Numbness in your face, ears or extremities?
(Required)
Yes
No
If yes, both sides, left or right?
Have you had:
(Required)
Weakness or clumsiness in arms, legs?
Pain in the neck or shoulders?
Slurred or difficult speech?
Difficulty swallowing?
Tingling around your mouth?
Spots before your eyes?
Jerking of arms or legs?
Seizures?
Confusion or memory loss?
None of the above
Select All
Have you had any recent head trauma?
(Required)
Yes
No
If yes, please explain.
Have you had any other sensation variables you feel are pertinent to your condition?
(Required)
Yes
No
If yes, please explain.
The following refers to your hearing. Select only those that apply and indicate which side has been affected:
Difficulty hearing in one ear?
Left
Right
Both
None
Ringing or buzzing in one ear?
Left
Right
Both
None
Fullness in one ear?
Left
Right
Both
None
Change in hearing and tinnitus volume when dizzy?
(Required)
Yes
No
Does your hearing fluctuate?
(Required)
Yes
No
Can you hear your heartbeat, eyes blinking, or any other internal sounds?
(Required)
Yes
No
If so, which sound and which ears?
Own voice excessively loud?
(Required)
Left
Right
Both
None
Have you had any other variables to do with your hearing you feel are pertinent?
(Required)
Yes
No
If yes, please explain.
Have you had any of the following?
Pain in ears?
(Required)
Left
Right
Both
None
Discharge from ears?
(Required)
Left
Right
Both
None
Hearing change for the better?
(Required)
Left
Right
Both
None
Hearing change for the worse?
(Required)
Left
Right
Both
None
Exposure to loud noises?
(Required)
Yes
No
Previous ear infections?
(Required)
Yes
No
Trauma to your ear(s)?
(Required)
Yes
No
Previous ear surgery?
(Required)
Yes
No
If yes, what kind?
Family history of deafness?
(Required)
Yes
No
Dizziness Questionnaire 4/5
Please submit this questionnaire prior to your appointment
I accept the above
The following refer to habits and lifestyle. Select only those that apply and answer as appropriate.
Is there added stress to your life recently?
(Required)
Yes
No
Is your dizziness related to:
(Required)
Moments of stress?
Menstrual period?
Overwork or exertion?
Hunger?
Emotional upset?
Changes in weather/atmospheric pressure?
Do you feel light-headed or have a swimming sensation when you are dizzy?
Do you find yourself breathing faster or deeper when excited or dizzy?
Did you recently change eyeglasses?
Have you ever had weakness or faintness a few hours after eating?
None of the above
Select All
Is your dizziness related to any of the following?
Do you drink coffee?
(Required)
Yes
No
How much and how often?
Do you drink tea?
(Required)
Yes
No
How much and how often?
Do you drink soft drinks?
(Required)
Yes
No
How much and how often?
Do you drink alcohol?
(Required)
Yes
No
How much and how often?
Do you smoke?
(Required)
Yes
No
What?
How much and how often?
Describe any other variables you feel may contribute to your dizziness:
Past medical history:
Please list your current medical problems and length of illness:
(Required)
Please list all surgery performed and approximate dates:
(Required)
Please list all allergies (including drugs) and reaction:
(Required)
Please list all medicines you currently take for your dizziness that HAVE provided some relief or benefit with your symptoms:
(Required)
Please list all medicines you currently take for your dizziness that HAVE NOT provided some relief or benefit for you:
(Required)
Please list all medicines you currently take (including pain medicine, nonprescription medicine, nerve pills, sleeping pills, or birth control pills).
(Required)
Have you had any previous testing eg hearing, x-rays, head scans, etc?
(Required)
Dizziness Questionnaire 5/5 - Please submit this questionnaire prior to your appointment
Family history:
Any family history of any of the following? Select all that apply.
(Required)
Migraine?
Off Balance/Vertigo/Dizziness or tinnitus?
High blood pressure?
Low blood pressure?
Diabetes?
Low blood sugar?
Thyroid disease?
Asthma?
Multiple Sclerosis?
Select All
Please list any other diseases that run in your immediate family:
Any other comments you feel are pertinent to your condition:
Declaration:
I confirm that for my appointment I will:
(Required)
Not wear make-up
Not eat anything for 8 hours prior
Have no caffeine for 12 hours prior
Have no alcohol for 48 hours prior
Have no nicotine (cigarettes, gum, patches etc) for 12 hours prior
Not take - tranquilisers, sedatives, vestibular suppressants (eg Stemetil, Serc) and painkillers for 24 hours prior
Select All
All information on this form is true and accurate
(Required)
Yes
No
We require all patients to follow the above guidelines for BOTH assessments. If these guidelines are not followed your appointment will be rescheduled to another date.
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