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Transcription:

VESTIBULAR HISTORY Name: Date of Birth: Age: Today's Date: Phone number Referring MD Next MD Appt: Briefly describe your problem: Describe: Date of onset: Time of day: What were you doing when it began? What were the first symptoms? How long did these symptoms last? Seconds Minutes Hours Days Constant Have you had more than one episode of dizziness? Yes No If yes, how often do these episodes occur? No, skip to Page 2 Since the first episode, are they becoming more or less frequent or no change? More frequent Less frequent No Change N/A Since the first episode, are they becoming more or less severe or no change? More severe Less severe No Change N/A Have you experienced nausea and/or vomiting? Yes No Describe anything that will stop the dizziness or make it better: Describe anything that makes the dizziness worse: Does anyone else in your family have problems with dizziness?: When you are dizzy do you experience: Difficulty with speech Confusion Spots, wavy lines or colored lights in vision Numbness, where? Weakness in arms or legs Tingling around your mouth Blurred vision or blindness Difficulty with swallowing Page 1 of 5

Ear and Hearing History (check any that apply) Loss of hearing: Right Left Tinnitus (noise in your ear(s)): Right Left Pressure/fullness in your ear(s): Right Left Ear infections, earaches or ear pain: Right Left Hole in your eardrum: Right Left Ear operations/surgery: Right Left Please describe: Have you experienced loud noise exposure in the past? Yes No Does your hearing fluctuate with dizzy episodes? Yes No Lifestyle Questions Do you drink alcohol? Yes No If yes, how many drinks per day? Do you smoke? Yes No If yes, how many cigarettes per day? Do you consume caffeinated beverages? Yes No If yes, how many cups per day? Do you exercise? Yes No If yes, how many times a week and for how long? Medications Please attach a list of all your current medications, including hormones, birth control pills, vitamins, etc. Please include the name of the medication, dosage and times per day taken. What medications have you taken specifically for your dizziness? List any medication allergies: Past Medical History Please check those items you have experienced and date of any treatment: Low back pain Neck pain Loss of feeling in feet Ankle sprain/fracture Neck injury Knee/Hip injury Eye problems Concussion Head injury High cholesterol Headaches Migraines Diabetes Low blood sugar Treatment Date Loss of vision HIV/AIDS Heart attack Cardiac surgery TMJ Recent dental work Stroke Seizure High cholesterol Unusual stress Panic attacks Treatment by psychologist Treatment by psychiatrist Depression Treatment Date Page 2 of 5

Previous Medical Tests Check all that apply. Please include the date of test, where the test was performed and the results of the testing if you know them (indicate by item number): 1. Hearing test 2. ENG (Electronystagmography) or VNG (Videonystagmography) 3. MRI of brain (Magnetic Resonance Imaging with contrast without contrast 4. MRI of ears with contrast without contrast 5. MRA (Magnetic Resonance Angiography) 6. CT Scan of brain 7. CT Scan of ears 8. ABR (Auditory Brainstem Response/Brainstem Auditory Evoked Response) 9. Balance Platform Test (Posturography) 10. Rotary Chair Test 11. VAT (Vestibular Autorotation Test) 12. ECOG (Electrocochleography) 13. EEG (Electroencephalogram) 14. EKG (Electrocardiogram) 15. Holter monitor testing for irregular heartbeat 16. Neck X-rays 17. Neurology Evaluation 18. Lumbar Puncture (Spinal Fluid Study) 19. Complete Physical Examination Rev. 09/12 Page 3 of 5

AUDIOLOGY DIZZINESS HANDICAP INVENTORY Name: Reason for visit: Date: Instructions: The purpose of this questionnaire is to identify difficulties that you may be experiencing because of your dizziness. Please answer every question. Please do not skip any questions. 1. Does looking up increase your problem? 2. Because of your problem, do you feel frustrated? 3. Because of your problem, do you restrict your travel for business or recreation? 4. Does walking down the aisle of a supermarket increase your problem? 5. Because of your problem, do you have difficulty getting into or out of bed? 6. Does your problem significantly restrict your participation in social activities such as going out to dinner, going to movies, dancing, or to parties? 7. Because of your problem, do you have difficulty reading? 8. Does performing more ambitious activities like sports, dancing, household chores such as sweeping or putting dishes away increase your problem? 9. Because of your problem, are you afraid to leave home without having someone with you? 10. Because of your problem, have you been embarrassed in front of others? 11. Do quick movements of your head increase your problem? 12. Because of your problem, do you avoid heights? 13. Does turning over in bed increase your problem? 14. Because of your problem, is it difficult for you to do strenuous housework or yard work? 15. Because of your problem, are you afraid people may think you are intoxicated? 16. Because of your problem, is it difficult for you to go for a walk by yourself? 17. Does walking down a sidewalk increase your problem? 18. Because of your problem, is it difficult for you to concentrate? 19. Because of your problem, is it difficult for you to go for a walk around your house in the dark? 20. Because of your problem, are you afraid to stay home alone? 21. Because of your problem, do you feel handicapped? 22. Has your problem placed stress on your relationship with members of your family or friends? 23. Because of your problem, are you depressed? 24. Does your problem interfere with your job or household responsibilities? 25. Does bending over increase your problem? Reference: The Development of the Dizziness Handicap Inventory Gary P. Jacobson, Ph.D.; Craig W. Newman, Ph.D. Arch Otolaryngol Head Neck Surg. 1990; 116(4):424 427 Page 4 of 5

Patient Name: Date of Birth: Medical Record Number: Please list all Doctors/Providers who referred you here, your primary care doctor, and any other doctor from whom you are receiving care. This information is required: Doctor who sent you to see us: Specialty: Primary Care Doctor/Provider: Page 5 of 5

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