Dizziness History Questionnaire

Name *

Date of Birth *

Email *

How did you hear about us?*
TelevisionRadioPhone BookInternet (Search Engine)Internet (Social Media)MailerFamily/FriendPhysicianOther

Have you ever experienced dizziness, lightheadedness, unsteadiness, or vertigo? *
YesNo

Are you feeling dizzy or unsteady today? *
YesNo

How often do you feel dizzy/unsteady? *

Describe in your own words how your dizziness or unsteadiness feels *

Is your dizziness/unsteadiness accompanied by *
nausearinging or noises in your ear(s)hearing lossvisual disturbancesOther

If other, explain

Have you fallen in the last 12 months due to your dizziness/unsteadiness? *
YesNo

If yes, how many falls have you experienced in the last 12 months?

If you have fallen, have you been injured? *
YesNo

If yes, please describe your injury

Do you tend to fall to the *
RightLeftBackFrontNo Pattern

Do you currently take a Vitamin D supplement? *
YesNo

Do you experience visual difficulties or disturbances? *
YesNo

If yes, please describe

When did your problem start? *

Was there any related event? *
YesNo

If yes, describe

Was the onset of your problem *
GradualSuddenOther

If other, describe

If your dizziness is not constant, do you have any warning the attacks will occur? *
YesNo

If yes, describe

If YES, do you have dizziness/unsteadiness between attacks?
YesNo

Does your dizziness/unsteadiness occur with position changes? *
YesNo

If yes, check all that apply
Rolling your body right or leftTurning your head left or rightLooking up, or head back positionBending over, or head down positionGoing from lying to sitting positionOther

If other, describe

Do you know of anything that makes your dizziness/unsteadiness better? *
YesNo

If yes, check all that apply
Not moving your headRestMedicationOther

If medication, describe *

If other, describe

Do you know of anything that makes your dizziness/unsteadiness worse? *
YesNo

If yes, check all that apply
Moving your headRiding or driving in the carLarge crowds or busy walkwaysWhen you’re hungry or haven’t eatenOther

If other, describe

Since it began, is your dizziness/unsteadiness currently *
BetterWorseSame

Do your symptoms limit your daily activities? *
YesNo

Do you have trouble walking in the dark or at dusk? *
YesNo

Do you have trouble walking on uneven surfaces (eg. lawn)? *
YesNo

When dizzy/unsteady, must you support yourself to stand or walk? *
YesNo

Do you have a history of migraine headaches? *
YesNo

Have you ever had IV antibiotics or chemotherapy? *
YesNo

Have you ever suffered a concussion (head injury)? *
YesNo

Do you have trouble sleeping? *
YesNo

Do you have pain, fullness, or pressure in your ears? *
YesNo

If yes, which ears
Right earLeft earBoth ears

If yes, does it coincide with your dizziness/unsteadiness?
YesNo

1. Double/blurred vision or blindness *
YesNo

If yes, is it
ConstantEpisodic

Comments

2. Numbness of face or extremities *
YesNo

If yes, is it
ConstantEpisodic

Comments

3. Weakness in arms or legs *
YesNo

If yes, is it
ConstantEpisodic

Comments

4. Clumsiness in arms or legs *
YesNo

If yes, is it
ConstantEpisodic

Comments

5. Confusion or loss of consciousness *
YesNo

If yes, is it
ConstantEpisodic

Comments

6. Difficulty with speech or swallowing *
YesNo

If yes, is it
ConstantEpisodic

Comments

Have you seen other healthcare providers for this problem?
YesNo

If yes, who?
Primary MDEar, Nose, Throat MD (ENT)NeurologistAudiologistCardiologistEmergency Room MDPhysical Therapist

ENG/VNG *
YesNo

Where

When

Results

MRI/CT *
YesNo

Where

When

Results

Hearing tests *
YesNo

Where

When

Results

Other

Signature *

Date *