Balance and dizziness questionnaire
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- Margery Cooper
- 5 years ago
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1 Balance and dizziness questionnaire Name: DOB: Date: Please describe in your own words, the sensation you feel without using the word dizzy Please circle the symptom that brought you here today: Please circle Spinning in circles Falling to one side World spinning around me My dizzy spells come in attacks How often? How long is the attack? Date of first attack: I am dizzier in certain positions? Which position?: I am free from dizziness between attacks My hearing changes with an attack Which ear?: I am dizzy if I stand up quickly I am nauseated during an attack I have had a recent cold or flu I have had fullness, pressure, or ringing in my ears I have had pain or discharge in my ears I have trouble walking in the dark I am better if I sit or lie perfectly still Loud sounds make me dizzy I black out or faint when dizzy I have severe or recurrent headaches I am sensitive to light during my headaches and/or dizziness I have double or blurry vision I have numbness in my face or extremities Dr. LM Hofmeyr MEDICLINIC MUELMED 13 Fairway Street OTOLOGIST AND NEUROTOLOGIST Room 505 Bellville MBChB(UP) MMED ENT (UP) 577 Pretorius Street 7530 HPCSA no Arcadia 0815 Cape Town Pr. No Pretoria (Opp MEDICLINIC LOUIS LEIPOLDT) Prof. LM HOFMEYR NEUROTOLOGIST INC T T Reg. no. inc 2013 / / 21 F F Reg. no. VAT C C lmhofmeyr@surgeon.co.za
2 I have weakness or clumsiness in my arms/legs I have slurred or difficult speech I have difficulty swallowing I have tingling around my mouth I see spots before my eyes I have jerking of my arms/legs I have seizures I have confusion or memory loss I have had recent head trauma The following refer to your hearing. Indicate which side has been affected: I have difficulty hearing in one ear Left Right Both I have ringing in one ear Left Right Both I have fullness in one ear Left Right Both I have a change in hearing when dizzy Left Right Both Have you had any of the following? pain in ears Left Right Both discharge in ears Left Right Both Hearing change Better Left Right Both Worse Left Right Both Exposure to loud noise Left Right Both Ear infections Left Right Both Trauma to ears Left Right Both Previous ear surgery Left Right Both Describe: I have a family history of deafness Left Right Both The following refer to habits and lifestyle There is added stress to my life recently I am dizzy or unsteady constantly Is your dizziness related to: Moments of stress? Menstrual period? Overwork or exertion? I feel lightheaded or swimming sensation when I am dizzy I breathe faster or deeper when excited or dizzy I recently changed eyeglasses I feel weak or faint a few hours after eating 2
3 I drink coffee I drink tea I drink soft drinks I drink alcohol I smoke What? Past medical history Please list your current medical problems and length of illness: Please list all surgery performed and approximate date: Please list all allergies (including drugs) and reaction: Please list all medications you currently take (including over the counter meds): Please list previous testing (hearing, x- rays, head scans, etc): Family History: Migraine who? High blood pressure who? Low blood pressure who? Diabetes who? Low blood sugar who? Thyroid disease who? Asthma who? Please list other diseases that run in your immediate family: 3
4 System review Circle all symptoms you currently have: Constitutional: Recent weight change Fever Fatigue Eyes: loss of vision Pain Discharge/tearing Ear, Nose, Mouth, Throat: Itchy ears Nasal obstruction Drooling Nosebleed Sneezing Stuffy nose Loss of sense of smell Growth in nose Bleeding from throat Mouth growth, ulcer Chewing difficulty Lump in neck Pain on swallowing Heartburn Sore throat Voice changes Breathing difficulty Nasal discharge Facial weakness Snoring Dental problems Cardiovascular: Chest pain Irregular heart beat Swelling of legs Leg pain with walking Leg pain with rest Gastrointestinal: Decrease in appetite Diarrhoea/Constipation Nausea/Vomiting Indigestion Blood in stool Food intolerance Respiratory: Wheezing Cough Shortness of breath Mucous Coughing up blood Musculoskeletal: Neck pain Joint pain/stiffness Arthritis name joint(s) Skin: Rash Jaundice Recent Baldness Neurological: Headache Tremor Blackout Seizures Paralysis 4
5 Psychiatric: Insomnia Depression On meds? Genitourinary: Painful urination Difficulty passing urine Venereal disease Incontinence Blood in urine Frequent urination at night Endocrine: Thyroid trouble Heat/Cold intolerance Excessive sweating Excessive thirst, hunger, urination Hematologic/Lymphatic: Bleeding problems Anaemia Easy bruising Blood disorder (such as Sickle Cell) Do you have anything else to tell us about your problem that we have not asked on this questionnaire? Physician Signature: Date: Permission and acknowledgement: Dr Joel A Goebel Goebel, J.A. (2008). Practical management of the dizzy patient (2nd edition). Wolters Kluwer 5
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NEW PATIENT INFORMATION FORM Name: LAST FIRST MIDDLE Date of Birth: Sex: Marital Status: SS Number: Address: City: State: Zip Phone: Home Cell Work Email: Communication Preference: Patient Portal Phone
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more
New Patient Sleep Intake
New Patient Sleep Intake Name: Date of Birth: Primary Care Physician: Date of Visit: Referring Physician and/or Other Physicians: Retail Pharmacy: Mail Order Pharmacy: Address: Mail Order Phone #: Phone
Aspire Pain Medical Center
Aspire Pain Medical Center Welcome to Aspire Pain Medical Center. We are looking forward to providing you with the best care to manage your needs. Please take the time to complete the following questionnaire
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma