QUESTIONNAIRE. This questionnaire will become a permanent part of the patient s medical record.
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1 David S. Zee, M. D. OCULOMOTOR/VESTIBULAR LABORATORY 1 QUESTIONNAIRE This questionnaire will become a permanent part of the patient s medical record. TODAY'S DATE: NAME: ADDRESS: DOB: HOME PHONE: WORK PHONE: CELL PHONE: ADDRESS: DR. ZEE HAS MY PERMISSION TO COMMUNICATE HEALTH INFORMATION VIA . IF YES SIGN HERE ARE YOU RIGHT OR LEFT HANDED? PRESENT OCCUPATION: PRIOR OCCUPATIONS: EDUCATION (HIGHEST LEVEL): REFERRING PHYSICIAN: NAME: ADDRESS: PHONE: FAX: PRIMARY CARE PHYSICIAN: NAME: ADDRESS: PHONE: FAX: (The patient will always receive a copy of the report. Please attach an additional page for any one else you would like to receive a copy.)
2 2 PLEASE ANSWER THE FOLLOWING QUESTIONS TO THE BEST OF YOUR ABILITY. PLEASE GIVE NECESSARY DETAILS FOR YES ANSWERS. There is additional room at the end of each section and at the end of the questionnaire for comments. If you do not have dizziness, answer all questions to the best of your ability. We realize that this form is long, but when it is filled out carefully, it allows us to devote more time to your specific problem, rather than asking you unrelated questions during your visit. 1. Describe your major problem and the reason why you are seeing us: 2. Please describe, in DETAIL, WHEN and the CIRCUMSTANCES in which the problem began and what were the initial symptom and problems. What might have caused the problem to begin? Unusual Exercise? Accident? Infection? Change in glasses? Change in type or dose of medications? Stress? Others? 3. If you have spells, please describe a typical spell in as much DETAIL as possible and also describe the TRIGGERS, TIME OF OCCURRENCE, FREQUENCY AND DURATION of the spells: 4. To what extent has your problem or spells changed since it first started? (for example: severity, frequency, and characteristics)?
3 5. Please mark each symptom and give details for all yes answers: 3 YES Trouble with walking? Trouble with balance? Any falls? Difficulty turning over in bed? Sense of motion of the environment? Sense of motion of one s own body? Sensation of one s body tilting? (which way?) Sensation of one s body pulling? (which way?) Sensation of rotation or spinning? (which way?) Sense of rocking? (which direction) Spinning inside of one s head? Sense of walking on pillows? Lightheadedness or faintness? Fear or avoidance of public places? Sweating? Nausea? Vomiting? Impaired vision? -Double vision? -images separated side-to-side?; up and down, tilted? -Blurred vision? -Flashes of light? -Jumping of vision? (when walking or riding?) -Trouble reading? Dry eyes? Dry mouth? Trouble with taste? Trouble with smell? 6. What do you think your problem is due to? 7. What have you been told your problem is due to?
4 4 8. How is your dizziness or imbalance affected or brought on by (give details): Severely Moderately Not at all Turning over in bed? Bending over, looking up? Standing up quickly? Rapid head movements? Walking in the dark? Walking on uneven surfaces (eg. grass or sand)? Elevators, escalators, or stairs? Airplane, boat or car travel? Scuba diving? Loud noises? Cough, sneeze, strain, or laugh? Moving objects (eg. computer screens, lights, windshield wipers, TV or movies)? Moving your eyes with your head still? Are you dizzy with eyes closed? Touching your ears? Wide-open or narrow spaces (eg. shopping malls, supermarket)? Tunnels, bridges, or heights? Thinking about or anticipating going to a type or specific place? Exercise (eg. aerobics, jogging)? Other activities (what)? Eating or missing meals? Special foods (salt, MSG, cheese, wine, chocolate, alcohol, caffeine)? Heat, hot showers or baths, or cold? Time of day? Swallowing? Depression, anxiety, or stress? GIVE DETAILS Menstrual periods? DETAILS:
5 9. Other Questions Concerning Dizziness: YES 5 Can you bring on your dizziness voluntarily? (if yes, please give details) Did you ever or do you have moderate to severe motion sickness? (car or boat, please describe) Did or do you ice skate, perform gymnastics or high intensity aerobics? Has anyone observed jerking of your eyes with dizzy spells? Have you had a caloric (air or water in the ear) test? Was the sensation induced similar to your own dizziness? Does your dizziness resemble the sensation provoked by spinning oneself round and round and then stopping? 10. Have you ever had: (if yes, please give details) YES Infections of the ears? Sinus disease? Inner ear disease (eg. labyrinthitis)? Difficulty with your hearing? (which ear and what type of difficulty?) Pain, fullness, popping or pressure in the ear? (which ear?) Ringing in the ears? (Tinnitus) Which ear? Steady or pulsating? High or low pitched? State the frequency and duration of the tinnitus: Pain, pins & needles, numbness, twitching, or weakness of face? Crossed eyes or lazy eye? Do you wear glasses? (for reading, far viewing or both?) Are you very nearsighted? 11. Have you had Migraine or other headaches? A. If yes, please answer the following: Approximate age they began: Frequency of headaches in last six months: Pain intensity (1 to 10 with 10 the most severe): B. If yes, do your headaches usually: YES Last 4 hours or more? Start on one side of the head? (front, back, left or right?) Throbbing or pulsatile (with the heart beat) in quality? Severe enough to interfere with your schedule? Related to diet? Related to menstrual periods? Aggravated by physical activity such as climbing stairs)? Brought on by cough, sneeze, laughing or strain? Associated with nausea and/or vomiting? Aggravated by bright lights or loud noises? Preceded by bright or flashing lights or zigzag lines?
6 YES 6 Usually relieved by going to a dark room? Usually relieved by sleep? Require medications? (which medications and how often?) Do you take pain medication more than 2 times per week? 12. Circle and give details of symptoms you have had in the last few years: Strength or energy change Appetite change Weight change (gain or loss, how much & over what period) Memory loss (amnesia) Skin rash or birthmarks Numbness in arms or legs Muscle aches Diarrhea Loss of bowel control Changes in sexual function Swollen glands Snoring or Sleep Apnea Abnormal menstrual periods Trouble chewing, swallowing Change in speech Stiffness Change in handwriting Sores in mouth or genitals Lump in throat Joint aches Heart palpitations Loss of bladder control Fevers or Chills Problems with going to or staying asleep Excessive daytime sleepiness or naps Shortness of breath Sweating Tremor or shakiness Incoordination 13. Have you had any injuries? (if yes, please explain) Ears? Eyes? Retinal detachment? Head? Neck (eg. whiplash)? Have you seen a Chiropractor? When? Miscarriages? Other injuries? 14. Have you had any surgery? (if yes, describe the surgery and when it occurred) Ears? Eyes? Head? Neck? Other?
7 15. Have you been exposed to or experienced any of the following? (if yes, please describe the exposure and when it occurred) 7 Poisons, gases, chemicals, or carbon monoxide? Tropical diseases? Tick bites? Long term (more than a week) intravenous antibiotics? Military service overseas? (where?) Travel to Central or South America, Asia, Africa? AIDS? Blood transfusions? Loud Noise? (eg. guns, machinery, loud music?) Drug therapy for cancer? (eg. Chemotherapy) (what type?) Medication for depression, anxiety, or other psychiatric disease? (Lithium, Valium or ativan, Dilantin, Tegretol, sleeping pills, antidepressants, tranquilizers? (WHAT TYPE, REASON, WHEN, HOW LONG?) SEE also item Has your past or present health been affected by: (if yes, please give details) Treatment by a psychiatrist or counselor? Depression, thought of harming yourself, feelings of worthlessness? Crying spells? Stress? Eating disorders or phobias? Anxiety or panic attacks? Heart problems? Diabetes? Low sugar (hypoglycemia)? Thyroid disorders? High cholesterol (triglycerides)? High or low blood pressure? Pain in back of jaw (TMJ), grinding? Loss of consciousness (fainting), seizures or convulsions? Blood diseases, anemia? Skin diseases? Arthritis? Neck pain? Lumps in breasts or testicles? 17. Have you had any of the following infections? (if yes, please give details) Syphilis or other sexually transmitted disease? Mononucleosis (Epstein-Barr)? Lyme disease? Meningitis? Other infections?
8 18. List all major illnesses, injuries, surgeries or miscarriage not described above: On the attached medication form, please list all of your current medications (include all medications, hormones, birth control pills, over the counter meds, vitamins, Viagra or similar medications, herbal medicines, other ALTERNATIVE THERAPIES and AMOUNT/DAY: 20. What other medications have you taken for your dizziness? include dosage, when, for how long, and effectiveness: 21. List all known allergies, including those to medication, or bad reactions to medicines. 22. SOCIAL HISTORY: YES Do or did you use alcohol? How much? How does alcohol affect your condition? Do or did you ever smoke? If so, how many packs/day? What age did you start? If you quit, at what age? Do or did you ever use drugs? LSD?, Cocaine?, Crack?, Marijuana? Do you drink coffee, decaf or sodas frequently? Do you use salt or eat salty foods? Do you have an unusual diet? Vegetarian?
9 What are your pets? 9 What are your hobbies? What is your favorite book? Are you married? divorced? widowed? single? Do you live alone? 23. Personality Would you describe yourself as: Obsessive Compulsive Prone to anxiety Hypochondriac Manic Down or depressed Melancholy or blue Phobic Do you set your watch ahead? How much? 24. FAMILY HISTORY Do you have children? If so, what are their ages? their health? Do you have brothers or sisters? If so, what are their ages? their health? Do you have any family members with: (please indicate which family member, include also Grandparents, Aunts, Uncles, Nieces, Nephews and Cousins) The same condition that you have? Migraine headaches? Meniere s syndrome? Hearing loss? Vertigo or dizziness? Balance problems? Tremor? Convulsions or seizures? Diabetes? Cancer? Kidney problems? Brain tumors? Stroke? Heart disease? High blood pressure? Psychiatric disorders, depression or panic attacks? Memory problems, dementia, or Alzheimer s? Other neurologic diseases? Any other conditions that run in the family? Mental retardation?
10 If your parents, brothers, sisters, or any children have died, at what age and from what cause? Have you had a: RESULT? WHEN? Hearing test? Evaluation by a neurologist? Evaluation by an ear doctor? Evaluation by an eye doctor? Caloric test? (water or air in ear) MRI? Was contrast given by injection? Brain Arteriogram? Carotid artery blood flow study? BAER? (auditory evoked potentials) VER? (visual evoked potentials) Sinus x-rays? Neck x-rays? MRI of neck or spine CT scan of the head or neck or spine? Spinal fluid examination EEG (Brain wave) 26. Have you recently had: RESULT? WHEN? Blood work? Urinalysis? Chest x-ray? Mammogram? GYN (pelvic) exam? Echocardiogram? Holter monitor (24 hours)? Tilt table test? Electrocardiogram Lyme test? Glucose tolerance test? B12 test? Thyroid test? AIDS test?
11 Handwriting specimen: Please write Whether or not you leave here early does not matter. 28. ADDITIONAL COMMENTS:
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