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Balance Tests
Treatment Program
Staff
Testimonials
Financial/Insurance
Appointments/Contact
Patient History
Legal Support
Patient History
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Patient History
If you are human, leave this field blank.
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.
