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Dizziness questionnaire

DALE B. SMITH, D.O.
TIMOTHY W. TEEL, D.O.

LONNIE C. SCHOLL, P.A.-C
MICHELE L. RO

GERS, Au.D.
4920 SW Lee Blvd, Lawton, OK 73505 (580) 536-8844
1015 E. Broadway, Ste. 103, Altus, OK 73521 (580) 477-1033

Dizziness Questionnaire
Date of Birth:
Gender: Male / Female
1) What term(s) best describe your “dizziness?”  Spinning sensation – the room / your body  Lightheaded  Other _________________________________________________________________________ 2) When did your episode first occur? _______________________________________________________
 How long did it last? _____ Minutes _____ Hours _____Days _____Constant  Has it changed since then? 3) When you try to walk, do you stumble to the  Right or  Left? 4) When was your last episode? ___________________________________________________________
How often do your episodes occur? ____ Minutes _____ Hours _____ Days  Few seconds  Seconds to minutes  Minutes to hours  Hours to days 5) During your episodes do you experience any of the following:  Noise or ringing in your ears  Visual blurring 6) What triggers or worsens your dizziness?  Turning over in bed  Hormonal changes  Other _____________________________________________________________________  Not moving  Opening my eyes  Eating / Drinking  Medications ____________  Other _____________________________________ 8) Have you changed any medications near the time your dizziness started? NO / YES __________________________________________________________________ 9) Have you or are you currently taking any of the following medications for dizziness: Do they help decrease your dizziness? YES / NO ****** Continued on Next Page ******
10) Do you have a history of any of the following: (if yes, please describe) ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________  Emotional / Psychiatric problems _________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________  Loss of Bowel or Bladder Control _________________________________________________  Paralysis or Loss of Feeling in the Body ____________________________________________ 11) Do you have a family history of any of the following:  Prior evaluation for dizziness _________________________________________________  Evaluation by an ENT Physician _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________  Other ______________________________________________________________________ 13) How would you describe your hearing:  Poor HEARING (Better in RIGHT / LEFT) 14) Do you usually have ear noises (tinnitus)? YES / NO EXTRA INFO ___________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

Source: http://www.allergyentinstitute.com/webdocuments/Dizziness-Questionnaire-2012.pdf

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CASA CIVIL DA PRESIDÊNCIA DA REPÚBLICA SECRETARIA EXECUTIVA/ARQUIVO NACIONAL COORDENAÇÃO REGIONAL NO DISTRITO FEDERAL Eu, _______________________________________________________________________________________, portador(a) da Carteira de Identidade nº_____________________________________, expedida pela _________, e do CPF nº__________________, filho(a) de_____________________

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A prospective 4-year follow-up study of attention-deficit hyperactivity and relateddisorders. J. Biederman, S. Faraone, S. Milberger, J. Guite, E. Mick, L. Chen, D. Mennin, A. Marrs, C. Ouellette, P. Moore, T. Spencer, D. Norman, T. Wilens, I. Krausand J. Perrin. Pediatric Psychopharmacology Unit, Massachusetts General Hospital,Boston, USA. JAMA (Journal of the American Medical Association) &

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