Dizziness questionnaire

DALE B. SMITH, D.O.
TIMOTHY W. TEEL, D.O.
LONNIE C. SCHOLL, P.A.-C
MICHELE L. RO
GERS, Au.D.
4920 SW Lee Blvd, Lawton, OK 73505 (580) 536-8844
1015 E. Broadway, Ste. 103, Altus, OK 73521 (580) 477-1033
Dizziness Questionnaire
Date of Birth:
Gender: Male / Female
1) What term(s) best describe your “dizziness?”  Spinning sensation – the room / your body  Lightheaded  Other _________________________________________________________________________ 2) When did your episode first occur? _______________________________________________________
 How long did it last? _____ Minutes _____ Hours _____Days _____Constant  Has it changed since then? 3) When you try to walk, do you stumble to the  Right or  Left? 4) When was your last episode? ___________________________________________________________
How often do your episodes occur? ____ Minutes _____ Hours _____ Days  Few seconds  Seconds to minutes  Minutes to hours  Hours to days 5) During your episodes do you experience any of the following:  Noise or ringing in your ears  Visual blurring 6) What triggers or worsens your dizziness?  Turning over in bed  Hormonal changes  Other _____________________________________________________________________  Not moving  Opening my eyes  Eating / Drinking  Medications ____________  Other _____________________________________ 8) Have you changed any medications near the time your dizziness started? NO / YES __________________________________________________________________ 9) Have you or are you currently taking any of the following medications for dizziness: Do they help decrease your dizziness? YES / NO ****** Continued on Next Page ******
10) Do you have a history of any of the following: (if yes, please describe) ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________  Emotional / Psychiatric problems _________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________  Loss of Bowel or Bladder Control _________________________________________________  Paralysis or Loss of Feeling in the Body ____________________________________________ 11) Do you have a family history of any of the following:  Prior evaluation for dizziness _________________________________________________  Evaluation by an ENT Physician _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________  Other ______________________________________________________________________ 13) How would you describe your hearing:  Poor HEARING (Better in RIGHT / LEFT) 14) Do you usually have ear noises (tinnitus)? YES / NO EXTRA INFO ___________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

Source: http://www.allergyentinstitute.com/webdocuments/Dizziness-Questionnaire-2012.pdf