VGN Forms

VGN Forms [ 994 KB]

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BALANCE TEST INSTRUCTIONS

An appointment has been made for you to have a test of your balance mechanism.





DIZZINESS QUESTIONNAIRE



 

I. When you are "dizzy" do you experience any of the following sensations? Please read the entire list first. Then select from the drop-down either YES or NO to describe your feelings most accurately.



II.  Please select from the drop-down for either YES or NO and fill in the blank spaces.



III. Do you have any of the following symptoms? Select the field YES or NO or the selection that applies to you.



IV. Have you ever experienced any of the following symptoms? Select either the YES or NO or the field that best answers the question.



V. Please select Yes or No