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Microsoft word - dizzinesshistoryquestionnaire

Name:_____________________________________________________ Age:_____ years I am right-handed/left-handed (Circle ONE) When is the first time ever in your life you had dizziness? ____________________________________________________________________________________ WHAT were the circumstances?__________________________________________________________ ____________________________________________________________________________________ Currently my dizziness…. (Check all that apply) ( ) is constant ( ) comes and goes ( ) is always there but waxes and wanes If it comes and goes: How long does it typically last?_________________________ seconds/minutes/hours (Circle ONE) How often does it typically occur?__________ times per hour/day/month/year (Circle ONE) My dizziness mostly consists of (Check ALL that apply) ( ) spells of spinning with nausea ( ) off-balance sensation without a dizzy sensation ( ) a light-headed or near-faint sensation ( ) other; Please explain:_______________________________________________________________ Between episodes, I feel (Check ONE): ( ) dizzy or off-balance all the time ( ) normal ( ) other; Please explain_______________________________________________________________ My episodes occur (Check ALL that apply) ( ) spontaneously. Nothing I do seems to bring them on or turn them office ( ) in relation to any head motion ( ) in relation to only certain head positions Describe___________________________________________________________________________ Did you cough, lift, sneeze, fly in an airplane, swim under water, or sustain head trauma shortly before the onset of your dizziness?.YES/NO If you had head trauma prior to your dizziness, did you lose consciousness completely?.YES/NO PAGE 2, continued When I roll over in bed (Check ONE): ( ) the room spins every time ( ) the room seems to spin sometimes ( ) nothing unusual happens Circle all that apply: I have hearing difficulty……………………………………………………………………………………… Left ear/Right ear I have ringing or other sounds…………………………………………………………………………… Left ear/Right ear I have fullness……………………………………………………………………………………………………. Left ear/Right ear
I have had ear surgery………………………………………………………………………………………. Left ear/Right ear
I consider myself to be an anxious or tense type of person:
……………………………………………………………………………………………………………… YES/NO
I am under a great deal of stress…………………………………………………………… YES/NO
In the past year I have had (CIRCLE):
Loss of consciousness…………………………………………………………………………… YES/NO
Seizure or convulsion……………………………………………………………………………. YES/NO
Slurring of Speech…………………………………………………………………………………. YES/NO
Weakness in one hand, arm or leg………………………………………………………… YES/NO
Numbness along one side of my body…………………………………………………… YES/NO
Double vision…………………………………………………………………………………………. YES/NO
Transient loss of vision…………………………………………………………………………… YES/NO
Severe pounding headache or migraine…………………………………………………. YES/NO
Palpitations of the heart beat…………………………………………………………………. YES/NO
Anxiety attacks………………………………………………………………………………………. YES/NO
I have or have had (CIRCLE):
Diabetes…………………………………………………………………………………………………. YES/NO
High blood pressure………………………………………………………………………………. YES/NO
Arthritis…………………………………………………………………………………………………. YES/NO
Head or neck pain…………………………………………………………………………………. YES/NO
Irregular heart beat………………………………………………………………………………. YES/NO
Stroke……………………………………………………………………………………………………. YES/NO
Please check below for any MEDICATIONS you have tried FOR DIZZINESS or are currently
taking:
PAGE 3, continued The effect of Antivert (meclizine) on my dizziness is (Check the ONE that applies): ( ) Never tried it Regarding my current state of overall function, not just during attacks (Check the ONE that best applies): ( ) 1. My dizziness has no effect on my activities. ( ) 2. When I am dizzy I have to stop what I am doing for awhile, but it soon passes and I can keep going. I continue to work, drive, and engage in any activity I choose without restriction and I have not changed any plans or activities to accommodate my dizziness. ( ) 3. When I am dizzy I have to stop what I am doing for awhile, but it does pass and I keep going. I continue to work, drive, and engage in most activities I choose, but I have had to make some allowance for my dizziness. ( ) 4. I am able to work, drive, travel, take care of my family, or engage in most essential activities, but I must exert a great deal of effort to do so. I must constantly make adjustments in my activities and budget my energies. I am barely making it. ( ) 5. I am unable to work, drive, or take care of my family. I am unable to do most of the active things I used to do. Even essential activities must be limited. I am disabled. ( ) 6. I am unable to walk more than a short distance. Even the simplest activity requires great effort and I am forced to rest afterwards. I cannot take care of my basic needs. I am totally disabled and virtually bedridden.

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