Please write your initials 1. Do you experience dizziness or a sense of physical imbalance? Yes No 2. When did your last episode of dizziness or imbalance occur? 3. Do your episodes of dizziness occur constantly or in attacks? Constantly In attacks 4. If applicable, how often are your attacks? Daily Weekly Monthly Other 5. When did your first experience of being dizzy or imbalance occur? 6. How long did your first episode of dizziness or imbalance last? 7. What symptoms, if any, precede your episodes of dizziness or imbalance? 8. Are you always somewhat dizzy or off balanced, even between episodes? Yes No 9. Does changing positions make you dizzy or imbalanced? (check all that apply) No Turning to the left while sitting Turning to the right while sitting Rolling to the left in bed Rolling to the right in bed Other 10. Do you have trouble walking in the dark? Yes No 11. Can you stand up unsupported when you are dizzy? Yes No 12. What do you think might be causing your dizziness or imbalance? 13. What, if anything, will stop your dizziness or make it better? 14. What, if anything will bring on an episode of dizziness or imbalance? 15. Do any of the following make you dizzy? (check all that apply) Walking in the supermarket Going up in a fast elevator Loud noises 16. Do you "hear" your eyes move? Yes, when in both ears Yes, in my right ear only Yes, in my left ear only No 17. Do your foot steps sound particularly loud? Yes, in both ears Yes, in my right ear only Yes, in my left ear only No 18. Please describe any relationship you may have noticed between eating and your dizziness or imbalance. 19. Please list any fumes paints etc. that you were exposed to at the onset of your dizziness or imbalance. 20. Please briefly describe any accidents (motor vehicle equipment etc.) that you have ever been involved in. 21. Please briefly describe any head injuries you may have suffered. 22. Were you unconscious as a result of a head injury or accident? Yes No 23. Were you dazed as a result of a head injury or accident? Yes No 24. Did your dizziness begin after an accident? Yes, after a car accident Yes, after a fall Yes, after another type of accident No 25. Please list any surgeries you have undergone. 26. Were there any complications from any surgeries you have undergone? Yes No I have not undergone any surgeries 27. When you are dizzy, do you experience any of the following sensations? (check all that apply) Light headedness Swimming sensation in head Blacking out Loss of conciousness objects spinning or turning around you sensation that you are turning or spinning inside, when outside objects remain stationary Headaches Pressure in the head Nausea or vomiting Tendency to fall to the right Tendency to fall to the left Tendency to fall backwards Tendency to fall forwards Loss of balance when walking Loss of balance while walking resulting in veering to the left Loss of balance while walking resulting veering to the right Double vision (in attacks) Double vision (constant) Blurred vision (in attacks) Blurred vision (constant) Blindness (in attacks) Blindness (constant) Hallucinations or seeing objects that aren't there (in attacks) Hallucinations or seeing objects that aren't there (constant) Numbness of face (in attacks) Numbness of face (constant) Numbness around mouth (in attacks) Numbness around mouth (constant) Numbness of your arms and/or legs (in attacks) Numbness of your arms and/or legs (constant) Difficulty with speech (in attacks) Difficulty with speech (constant) Difficulty swallowing (in attacks) Difficulty swallowing (constant) Difficulty hearing 28. Please describe any sensations you may experience when you are dizzy that are not listed above. 29. Do you experience difficulty hearing when you are dizzy? Yes, in both ears Yes, in right ear only Yes, in left ear only No 30. If applicable, for how long have you had a hearing loss? (Please specify if there has been a difference between the left and right ears) 31. If applicable, Is your hearing loss constant? Yes, in both ears Yes, in right ear only Yes, in left ear only No 32. Do you experience hearing any unexplained noise in your ears? Yes, in both ears Yes, in right ear only Yes, in left ear only No 33. Please, describe the noise. 34. Is the unexplained noise constant? Yes No I do not experience any unexplained noise 35. If applicable, for how long have you had unexplained noise in your ear(s)? (Please specify if there is a difference for each ear.) 36. If applicable, does the noise change with dizziness? Yes No I do not experience any unexplained noise 37. If applicable, how does the noise change with dizziness? 38. Does the volume of the noise change in a noisy place? Yes, the volume of the noise increases Yes, the volume of the noise decreases No I do not experience any unexplained noise 39. Does the volume of the noise change in a quiet place? Yes, the volume of the noise increases Yes, the volume of the noise decreases No I do not experience any unexplained noise 40. Does the volume of the noise change in daytime? Yes, the volume of the noise increases Yes, the volume of the noise decreases No I do not experience any unexplained noise 41. Does the volume of the noise change at night? Yes, the volume of the noise increases Yes, the volume of the noise decreases No I do not experience any unexplained noise 42. Do you have fullness, stuffiness or pressure in your ears? Yes, in both ears Yes, in my right ear only Yes, in my left ear only No 43. If applicable, for how long have you had pressure in your right ear(s)? (Please, specify if there is a difference for left and right ear.) 44. Do you have any pain in your ears? Yes, in both ears Yes, in my right ear Yes, in my left ear No 45. How would you describe the pain in your ears? Constant It comes in attacks I do not have any pain in my ears 46. Have you ever experienced any discharge from your ears? Both Right Left I have not experienced any discharge from my ears 47. If applicable, when did you first experience discharge from your ear(s)? (Please specify if there is a difference between your left and right ears) 48. Do you have a ear discharge now? Yes, from both ears Yes, from right ear only Yes, from left ear only No 49. Have you ever been exposed to loud noise(s)? Yes No 50. If applicable, for how long were you exposed to the loud noise(s)? 51. If applicable, for how many years were you exposed to loud noises? 52. Did you have ear protection while being exposed to loud noise(s)? Yes No I have not experienced loud noise(s) 53. Please list any allergies you have. 54. Please list any medication you are currently taking. Please include dose and frequency. 55. Do you drink alcohol? Yes No 56. When was the last time you had a drink? 57. Do you use tobacco in any form? Yes No 58. Are you under any unusual strain or tension? Yes No 59. Do you experience pain or clicking in your jaw? Yes No 60. Does your pain or clicking in your jaw change when you are eating? Yes No I do not experience any pain or clicking in my jaw 61. Do you have any problems with your vision? Yes No 62. If applicable, Please describe your vision problems. 63. Do you have any orthopedic problems (bone / joint) Yes No 64. If applicable, please describe your orthopedic problems (bone/joint). 65. Do you have arthritis problems? Yes No 66. If applicable, please describe any arthritis problems. 67. Do you have any problems walking? Yes No 68. If applicable, please describe any problems you have walking. 69. Have you ever had any of the following? (Please check all that apply) Syphillis High blood pressure Stroke Multiple Sclerosis A lack of blood to the brain Brain tumor Diabetes Ear infection Mastoid infection Thyroid gland problems Anemia Cancer Lyme disease Migraine 70. Has anyone in your family had hearing problems dizziness or vertigo? Yes No 71. Please indicate any other information regarding your symptoms, which you feel is not mentioned in the above questions.