Name

Time

Date:

Name

Date:

1. Lightheadedness Select Yes No

2. Swimming sensation in the head Select Yes No

3. Blacking Out Select Yes No

4. Loss of Consciousness Select Yes No

5. Tendency to fall: Select No To the Right To the Left Forward Backward

6. Objects spinning or turning around you. Select Yes No

7. Sensation that you are turning or spinning inside, with outside objects remaining stationary. Select Yes No

8. Loss of balance when walking: Select No Veering to the right Veering to the left

9. Headache Select No No

10. Nausea or Vomiting Select Yes No

11. Pressure in the head Select Yes No

1. My dizziness is constant? Select Yes No

2. When did dizziness first occur?

3. If in attacks: How often?

4. Are you completely free of dizziness between attacks? Select Yes No

5. Does dizziness occur only in certain positions? Select Yes No

6. Do you have trouble walking in the dark? Select Yes No

7. When you are dizzy, must you support yourself when standing? Select Yes No

8. Do you know of any possible cause of your dizziness? Select Yes No

9. Do you know of anything that will?

10. Were you exposed to irritation fumes, paints, etc at the onset of dizziness? Select Yes No

11. Do you have any allergies? Select Yes No

12. Did you ever injure your head? Select Yes No

13. Do you take any medicaitons regularly (i.e. tranquilizers, oral contraceptives, barbiturates, antibiotics?) Select Yes No

14. Do you use tobacco in any form? Select Yes No

15. Do you use alcohol? Select Yes No

16. Have you ever had ear surger? Select Yes No

1. Difficulty in hearing Select Both Ears Right Left

2. Noise in your ears? Select Both Ears Right Left

3. Fullness or stuffiness in your ears? Select Both Ears Right Left

Does this change when you are dizzy? Select Yes No

4. Pain in your ears? Select Both Ears Right Left

5. Discharge from your ears? Select Both Ears Right Left

1. Double Vision Select Yes - Constant Yes - In Episodes No

2. Numbness of face or extremities Select Yes - Constant Yes - In Episodes No

3. Blurred vision or blindness Select Yes - Constant Yes - In Episodes No

4. Weakness in arms or legs Select Yes - Constant Yes - In Episodes No

5. Clumsiness in arms or legs Select Yes - Constant Yes - In Episodes No

6. Confusion or loss of consciousness Select Yes - Constant Yes - In Episodes No

7. Difficulty with speech Select Yes - Constant Yes - In Episodes No

8. Difficulty with swallowing Select Yes - Constant Yes - In Episodes No

9. Tingling around the mouth Select Yes - Constant Yes - In Episodes No

10. Spots before the eyes Select Yes - Constant Yes - In Episodes No

1. Do you get dizzy after exertion or overwork? Select Yes No

2. Did you get new glasses recently? Select Yes No

3. Do you tend to get upset easily? Select Yes No

4. Do you get dizzy when you have no eatenfor a long time? Select Yes No

5. Is your dizziness connected with your menstrual period? Select Yes No

6. Have you ever had a neck injury? Select Yes No