Instructions for BPPV Testing

Instructions for BPPV Testing You are scheduled for a balance workup on With: Paige Pierozynski, AuD Bernice A. McKenzie, AuD Please report to: The Hearing & Dizziness Clinic 35 Victoria Ave, Essex ON (519) 961-9285 Enclosed you will find several questionnaires regarding your dizziness and balance workup. Please complete these to the best of your ability and bring them along to our office when you attend your appointment. On the day of your appointment, there may be several tests completed during this balance work up. These test are designed to evaluate the various portions of your hearing and balance systems. Depending on your symptoms, some of the tests that may be completed at your appointment are described below: 4. 1. Hearing test This test evaluates your hearing system. You will be asked to sit in a chair in a sound shielded room. 2. Dix-Hallpike Maneuver This maneuver is used to diagnose BPPV. The Audiologist will help you lie down backwards quickly with the head held in a specific position, while she watches your eyes. If the result is positive, your eye movements will tell her which ear is affected by BPPV. 3. The Epley Maneuver This maneuver is used to treat benign paroxysmal positional vertigo (BPPV) of the posterior or anterior canals. The BPPV evaluation can take 1-1.5 hours. These results will help your doctor and the audiologist to diagnose and treat your dizziness problem. Please feel free to bring a family member or friend to your appointment if you wish. FOR AT LEAST 2 DAYS PRIOR TO THE TEST: NO Dizziness Medication NO Alcoholic Drinks (In any amount) NO Pain medication, tranquilizers, antihistamines and/or sedatives (NOTE Do NOT stop taking medicines taken for seizures, heart disease and hypertension. If you have any questions about whether or not to stop your medications, consult your doctor. ) THE DAY OF YOUR TEST: EATonly a very light meal 2-3 hours before the test (tea, toast, broth, etc.) WEAR comfortable clothing We respectfully ask that if you cannot attend your scheduled appointment, to call us at any time to reschedule. This will enable us to open up otherwise unused appointments to better serve all patents. There will be a fee assessed for our services should we not receive a cancelation of an appointment. Should you have any questions, please feel free to contact our office at (519) 961-9285

35 Victoria Ave, Essex ON N8M 1M4 PH: 519.961.9285 FAX: 519.961.9414 www.hearinganddizzy.ca Dizziness & Balance Medical History Questionnaire You may want to reference your previous medical history records and/or ask a friend or family member familiar with your condition to help you. Today s Date: Name: Referring Physician: Date of Birth: I. INITIAL ONSET Briefly describe what happened the first time you experienced dizzy/imbalanced symptoms: II. HISTORY OF PRESENT ILLNESS i. When did you problem start (date)? ii. Was it associated with a related event (i.e. Head injury)? Yes No iii. iv. If yes, please explain: Was the onset of your symptoms: Sudden Gradual Overnight Other Of other, please describe: Are the symptoms: Constant Variable (i.e. come and go in spells) If variable: a. The spells occur every (# of): hours days weeks months years b. The spells last: Seconds Minutes Hours Days c. Do you have any warning signs that a spell is about to happen? Yes No If yes, please describe: d. Are you completely symptom free between spells? Yes No3 v. Do your symptoms occur when changing positions? Yes No If yes, check all that apply: Position Rolling your body to the left Moving from a lying to a sitting position Turning head side to side while sitting/standing Position Rolling your body to the right Looking up with your head back Bending over with your head down

vi. Is there anything that makes your symptoms better? Yes No If yes, please explain: vii. Is there anything that makes your symptoms worse? Yes No viii. ix. If yes, check all that apply: Activity/Situation Moving my head Riding or driving in the car Loud sounds Standing up Time of day Stress/Anxiety Do you experience motion, air or seasickness? Activity/Situation Physical activity or exercise Large crowds or a busy environment Coughing, blowing the nose or straining Eating certain foods Menstrual periods Other: Yes No Did you experience motion, air or seasickness as a child? Yes No When you have symptoms, do you feel the need to support yourself to stand and/or walk? Yes No If yes, how do you support yourself? x. When walking, do you ever: veer left? veer right? remain in a straight path? xi. xii. Have you ever fallen as a result of your current problem? Yes No If yes, how many times? Do you have a fear of falling? Yes No Where? Inside the home Outside the home xiii. Do you have any associated ear symptoms? Yes No If yes, please check the symptom and circle the ear which is affected: Symptom Circle which ear is affected Hearing difficulty Both Left Right Noises in the ear Both Left Right Ear pressure/fullness Both Left Right Ear drainage Both Left Right Ear pain Both Left Right History of noise exposure Both Left Right Perforated ear drum Both Left Right xiv. When dizzy or imbalanced, do you experience any of the following: Symptom Yes No Light headedness or a floating sensation? Objects or your environment turning around you? A sensation that you are turning or spinning while the environment remains stable? Nausea or vomiting? Tingling in your hands, feet or lips?

III. MEDICAL HISTORY i. Please check all that apply Condition Parkinson s Disease Fatigue Multiple Sclerosis Migraines Ulcer High Blood Pressure Thyroid Disease Tumor or Cancer Circulation Problems Diabetes Stroke Heart Attack/Disease Arthritis Glaucoma Macular Degeneration Tobacco Use If yes, how much? Other: Condition Depression Loss of limb (arm, leg) Osteoporosis Headaches Memory Loss Anemia Sinusitis Asthma/Allergies Head or Neck Injury Visual Problems/Eye Disorders Seizures/Convulsions Pulmonary/Respiratory Problems Hip or Leg Problems Cataracts Neck or Back Problems Alcohol Use If yes, how much? When was your last drink? ii. Please list all medications that you are presently taking: iii. Prior relevant medical evaluations, diagnostic testing and treatment: a. Have you seen other healthcare providers for your condition? Yes No If yes, who? Family Doctor ENT specialist Neurologist Cardiologist Emergency Room Doctor Other: b. Have you had any of the following done for this condition elsewhere? Test/Therapy When Where Results ENG/VNG CT SCAN or MRI Hearing Test Rehabilitation Did it help? Yes No Eye Exam

IV. EMPLOYMENT INFORMATION: Full time Part time Retired Not Employed Prefer not to answer Employer: Have you ever been exposed to any solvents, chemicals, etc.? Yes No V. ADDITIONAL INFORMATION Is there anything else you would like to make sure to tell your Audiologist about?

Vestibular Disorders of Daily Living Scale This scale evaluates the effects of vertigo and balance disorders on independence in routine activities of daily living. Please rate your performance on each item. If you performance varies due to intermittent dizziness or balance problems, please use the greatest level of disability. For each task, indicate the level which most accurately describes how you perform the task. If you never do a particular task, please check the box in the column NA. The rating scales are explained on the back of the page. Independence Rating 1 = Independent 6 = Must use an object for help 2 = Uncomfortable, No change in ability 7 = Must use special equipment 3 = Decreased ability, No change in Manner of Performance 8 = Need physical assistance 4 = Slower, Cautious, More careful 9 = Dependent 5 = Prefer using an object for Help 10 = Too difficult, no longer perform NA Task 1 2 3 4 5 6 7 8 9 10 NA F1 Standing up from lying down F2 Standing up from sitting on the bed or chair F3 Dressing the upper body (i.e. shirt or undershirt) F4 Dressing the lower body (i.e. pants, skirt) F5 Putting on socks or stockings F6 Putting on shoes F7 Moving in or out of the bathtub or shower F8 Bathing yourself in the bathtub or shower F9 Reaching overhead (i.e. to a cupboard or shelf) F10 Reaching down (i.e. to the floor or a shelf) F11 Meal preparation F12 Intimate activity (i.e. foreplay, sexual activity) A13 Walking on level surfaces A14 Walking on uneven surfaces A15 Going up steps A16 Going down steps A17 Walking in narrow spaces (i.e. hallway, aisle) A18 Walking in open spaces A19 Walking in crowds A20 Using an elevator A21 Using an escalator I22 Driving a car I23 Carrying things while walking (i.e. garbage bag) I24 Light household chores (i.e. dusting, tidying) I25 Heavy household chores (i.e. vacuuming) I26 Active recreation (i.e. sports, gardening) I27 Occupational role (i.e. job, child care, student) I28 Traveling around the community (i.e. car, bus)

Dizziness Handicap Inventory Instructions: The purpose of this questionnaire is to identify difficulties that you may be experiencing because of your dizziness or unsteadiness. Please answer Yes, No, or Sometimes to each question. Answer each question as it pertains to your dizziness problem only P1. Does looking up increase your problem? E2. Because of your problem do you feel frustrated? F3. Because of your problem do you restrict your travel for business or recreation? P4. Does walking down the aisle of a supermarket increase your problem? F5. Because of your problem do you have difficulty getting out of bed? F6. Does your problem significantly restrict your participation in social activities such as going out to dinner, the movies, dancing or to parties? F7. Because of your problem do you have difficulty reading? P8. Does performing more ambitious activities like sports, dancing, household chores such as sweeping or putting dishes away increase your problem? E9. Because of your problem are you afraid to leave your home without having someone accompany you? E10. Because of your problem have you been embarrassed in front of others? P11. Do quick movements of your head increase your problem? F12. Because of your problem do you avoid heights? P13. Does turning over in bed increase your problem? F14. Because of your problem is it difficult for you to do strenuous housework or yard work? E15. Because of your problem are you afraid people may think you are intoxicated? P16. Because of your problem is it difficult for you to go for a walk by yourself? P17. Does walking down a sidewalk increase your problem? E18. Because of your problem is it difficult for you to concentrate? F19. Because of your problem is it difficult to walk around the house in the dark? E20. Because of your problem are you afraid to stay home alone? E21. Because of your problem do you feel handicapped? E22. Has your problem placed stress on your relationships with members of your family and friends? E23. Because of your problem are you depressed? F24. Does your problem interfere with your job or household responsibilities? P25. Does bending over increase your problem? YES (4) Sometimes (2) No (0) F = Functional E = Emotional P = Physical Total Score

Adult Binocular Vision Dysfunction Questionnaire Directions: For each of the following questions, please check the answer that best describes your situation. If you wear glasses or contact lenses, answer the questions assuming that you are wearing them. Please answer every question. Never = NeverOccasionally = Less than 1 time / week Frequently= At least 1 time / week Always = Everyday 1 Do you have headaches or facial pain? 2 Do you have pain in your eyes with eye movement? 3 Do you experience neck or shoulder discomfort? 4 Do you experience dizziness and/or light-headedness? Do you experience dizziness, light-headedness or nausea while performing close up 5 activities i.e. computer work, reading, writing? Do you experience dizziness, light-headedness or nausea while performing far 6 distance activities, i.e. driving, watching television, movies? Do you experience dizziness, light-headedness or nausea when bending down and 7 standing back up or when quickly getting up from a seated or laying position? 8 Do you feel unsteady with walking, or drift to one side while walking? 9 Do you feel overwhelmed or anxious while walking in a large department or grocery store? 10 Do you feel overwhelmed or anxious while in a crowd? 11 Does riding in a car make you dizzy or uncomfortable? 12 Do you experience anxiety or nervousness because of your dizziness? 13 Do you ever find yourself with your head tilted to one side? 14 Do you experience poor depth perception or have difficulty estimating distances accurately? 15 Do you experience double / overlapping / shadowed vision at far distances? 16 Do you experience double / overlapping / shadowed vision at near distances? 17 Do you experience glare or have sensitivity to bright lights? 18 Do you close or cover one eye with near or far tasks? 19 Do you skip lines or lose your place while reading (do you use your finger or a ruler or other guides to maintain your position on the page)? 20 Do you tire easily with close-up tasks (computer work, reading, and writing)? 21 22 23 Do you experience blurred vision with far-distance activities (i.e. - driving, television, movies, and chalkboard at school)? Do you experience blurred vision with close-up activities (i.e. - computer work, reading, and writing)? Do you blink to clear up distant objects after working at a desk or working with closeup activities (i.e. - computer work, reading, and writing)? 24 Do you experience words running together with reading? 25 Do you experience difficulty with reading or reading comprehension? N O F A

Have you ever been diagnosed with a traumatic brain injury (TBI)? Yes No On an average day, how much are you bothered by the 8 symptoms listed below? (Rate each symptom from 0 to 10, where 10 is the worst it could be, and where 0 means you have none of that symptom) Dizziness / 10 Nausea / 10 Anxiety / 10 Headache / 10 Neckache / 10 Unsteady when walking / 10 Sensitivity to light / 10 Reading difficulty / 10