Dizziness history questionnaire

NAME:____________________________________AGE:__________ DATE: ____________ When was the first time ever in your life you had dizziness? ____________________________________________________________________________ What were the circumstances? ____________________________________________________________________________ ____________________________________________________________________________ When was the last time you experienced dizziness? _____________________________________________________________________________ What were the circumstances? _____________________________________________________________________________ _____________________________________________________________________________ Currently, my dizziness…. (Check one) _____ is constant. _____ is always there, but changes in intensity. _____ comes and goes. If it comes and goes: How long does it last? ____ seconds / minutes / hours (circle one) How often does it typically occur? ____ times per hour / day / week/ month / year My dizziness mostly consists of… (Check ALL that apply) _____ spells of spinning with nausea. _____ off-balance sensation without dizziness. _____ a light-headed or near faint sensation. _____ other. Please explain ___________________________________________________________________________ Between episodes I feel… (Check one) _____ dizzy or off balance at all times. _____ normal. _____other. Please explain ______________________________________________________________________________ My episodes occur…(check ALL that apply) _____ spontaneously. Nothing I do seems to bring them on or turn them off. _____ only when standing or walking. _____ in relation to any head motion. _____ in relation to only certain head positions. Please describe ______________________________________________________________________________ When I roll over in bed…(check one) _____ nothing unusual happens. _____ the room seems to spin sometimes. _____ the room spins every time. Is there anything that you can do to make your dizziness go away? (sit, lay down, close eyes…) Please explain. ____________________________________________________________________________ Circle all that apply: I have hearing difficulty Circle YES or NO Did you have a cold, flu, or virus type symptoms shortly before the onset of your dizziness? Did you cough, lift, sneeze, fly in a plane, swim under water, have a head trauma shortly before the onset of your dizziness? If you had head trauma prior to your dizziness, did you lose consciousness completely? Were you exposed to any irritating fumes, paints, etc. at the onset of your dizziness? Do you get dizzy when you have not eaten for a long time? I consider myself to be an anxious or tense type of person. In the past year I have had…(check all that apply) ___ loss of consciousness ___spots before the eyes I have or have had…(check all that apply) ___Diabetes Please check below for any medications you have tried or are currently taking for dizziness: Have you ever been previously evaluated for dizziness? ________________________________________________________________________ ________________________________________________________________________

Source: http://www.aclhearingcenters.com/files/dizziness_history_questionnaire.pdf

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