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.
WELLCARE NEW YORK HEALTHPLANS PROVIDER PREFERRED DRUG LIST HANDBOOK - 2006 CHILD HEALTH PLUS AND FAMILY HEALTH PLUS Cost Index Quality Indicator QTY / Therapeutic Limit Specific Limitations Generic Name Brand Name (Optional Info) ANALGESICS Opioid Analgesics LORCET, LORTAB- 2.5/500, 5/500, 7.5/500, 7.5/650, 10/650, 10/500, ELIXIR, VICODIN 10/660, 7.5/750METHADO