Patients Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
When did your dizziness begin?
*
How long do your “Dizzy spells” last?
How often do they occur in a weekly period?
List any medications you are taking for dizziness:
Do you have?
Arthritis
Diabetes
Eye Pain
Headaches
High Blood Pressure
Multiple Sclerosis
Peptic Ulcer Disease
Seizure Disorder
Visual Problems
Is it present at all times?
Yes
No
Did it begin following a “cold”, “flu”, or symptoms of an upper respiratory tract infection (cough, runny nose, fever, sore throat, or congestion)?
*
Yes
No
Do you experience Vertigo – a “whirling” or “spinning” sensation of your surroundings or yourself?
*
Yes
No
Do you describe your dizziness as lightheadedness?
*
Yes
No
Do your “Dizzy Spells” ever occur when you are sitting in a chair watching television?
*
Yes
No
Do you experience imbalance?
*
Yes
No
Have you suddenly lost hearing prior to or during the onset of your dizziness?
*
Yes
No
Do you experience any of the below with your dizziness?
Decreased hearing or a “stopped up – fullness” sensation of the ears?
*
Yes
No
Increased “ringing” or other noise of the ears?
*
Yes
No
Change in vision?
*
Yes
No
Numbness or weakness in parts of your body?
*
Yes
No
“Blackout spells” where you fall or lose consciousness?
*
Yes
No
Can you “bring on” your dizziness with:
Sudden head movements.
*
Yes
No
Lying down in bed.
*
Yes
No
“Rolling over” in bed.
*
Yes
No
Getting up out of bed or chair rapidly.
*
Yes
No
“Bending over” and “raising up”.
*
Yes
No
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