Survey Regarding Vestibular (Inner Ear) & Disequilibrium

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Survey Regarding Vestibular (Inner Ear) & Disequilibrium

Transcript Of Survey Regarding Vestibular (Inner Ear) & Disequilibrium

Survey Regarding Vestibular (Inner Ear) & Disequilibrium (Balance) Symptoms
Today’s Date: ____________
Name: _____________________________________ Birthdate: ____________ Referring Physician: ________________________________________________ Primary Care Physician: _____________________________________________ Without using the word “dizzy”, describe the sensations you experience:
____________________________________________________________________________________ ____________________________________________________________________________________
The following questions relate to vestibular sensations and/or imbalance. I. DO YOU EXPERIENCE ANY OF THE FOLLOWING SENSATIONS?
Yes No Turning or spinning of yourself in a room or open space Yes No Drifting toward or falling toward one side Yes No Objects in the environment turning or spinning or moving around you
II. HAVE YOU EXPERIENCED ANY OF THE FOLLOWING SENSATIONS? Yes No Black outs or fainting with dizziness Yes No Severe or recurrent headaches Yes No Abnormal sensitivity to light with headaches or dizziness Yes No Numbness in your face, around your lips, or in your extremities Yes No Weakness or clumsiness in your  arms  legs  left side  right side  both sides Yes No Slurred or difficult speech Yes No Difficulty swallowing Yes No Tingling around your mouth Yes No Spots before your eyes Yes No Vision with  double images  blurred images Yes No Unusual jerking of  arms  legs Yes No Seizures Yes No  Confusion or  Memory loss. Yes No Recent head trauma? If yes, please explain Yes No Bothersome pain?  Low Back  Neck  Knees  Hips  Shoulders  Hands
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Yes No Do your “dizzy” spells come in attacks? How often? Typically how long does each attack persist? Date of your first episode? How long did your first episode persist? After the first several days, are you  improving  worsening  same
Yes No Are you free from “dizziness” between attacks? Yes No Is “dizziness” constant, with fluctuations in intensity?
Of your attacks, what is the shortest duration ______ The longest duration ______ Yes No Did your hearing change with your first attack? Yes No Does your hearing fluctuate? Yes No Is “dizziness” mainly provoked by quickly sitting or standing up? Yes No Do certain positions make you “dizzier” or provoke “dizziness”?
Which position(s)? Yes No Are you nauseated during attacks?  With vomiting  Without vomiting Yes No Are you “dizzy” even when lying down without movement? Yes No Is robust dizziness related to rolling  onto your left side  right side? Yes No Did you have cold or flu preceding recent dizzy spells? Yes No Do you perceive fullness, pressure, or ringing in your ears?  Left  Right  Both Yes No Have you experienced ear pain or discharge from your ear(s) with “dizziness”? Yes No Did you, or do you have, difficulty walking in the dark? Yes No Does avoiding movement make you feel better? Yes No Do you experience imbalance? Yes No Do you drift  left  right or  side to side when walking? Yes No Do grocery store aisles, narrow hallways, or crowds create dizziness and imbalance? Yes No Do you touch furniture, walls, or people to maintain or regain balance? Yes No Do loud sounds make you “dizzy”?


Yes No Upper Respiratory Infection Yes No Shingles Yes No Dehydration

Yes No Bacterial Infection Yes No Other Viral Infection Yes No Migraine

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Yes No Difficulty hearing Yes No Ringing (Tinnitus) Yes No Roaring (Tinnitus) Yes No Fullness (pressure) Yes No Change in hearing when “dizzy” Yes No Pain (Otalgia) in ears Yes No Discharge from ears Yes No Family history of deafness Yes No Significant exposure to loud noises Yes No Previous ear infections Yes No Trauma/surgery to your ear(s). What type? Yes No Hearing change associated with dizziness and imbalance?  Better  Worse


VI. THE FOLLOWING ITEMS REFER TO HABITS AND LIFESTYLES: Yes No Has significant new stress been added to your life recently? Yes No Are you dizzy or unsteady constantly? Yes No Are you dizzy or unsteady intermittently? Yes No Have you fallen because of dizziness and/or imbalance? Yes No Do you fear you might fall because of dizziness or imbalance? Yes No Is your work affected by your symptoms?

VII. IS YOUR DIZZINESS RELATED TO: Yes No Moments of stress Yes No Menstrual cycle Yes No Headache or migraine symptoms without headache Yes No Overwork or overexertion Yes No Do you feel lightheaded or have a swimming/drunken sensation when dizzy? Yes No Do you have dizziness when straining in the bathroom, sneezing, or heavy lifting? Yes No Do you find yourself breathing faster or deeper when excited or dizzy? Yes No Did you recently change glasses or contact lenses? Yes No Have you ever experienced weakness or faintness a few hours after eating? Yes No Do you drink coffee? How much? Yes No Do you drink tea? How much? Yes No Do you drink soft drinks? How much? Yes No Do you drink alcohol? How much? Yes No Do you smoke? How much?

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VIII. PATIENT & FAMILY HISTORY: Yes No Migraine Yes No High blood pressure Yes No Low blood pressure Yes No Diabetes Yes No Low blood sugar Yes No Thyroid disease Yes No Asthma or COPD

Yes No Autoimmune disease Yes No Cancer Yes No MS (Multiple Sclerosis) Yes No Parkinson’s disease Yes No Stroke Yes No Lupus Yes No Alzheimer’s/Dementia



Constitutional  Recent weight change  Fever

 Fatigue


 Loss of vision  Left  Right  Both

Ear, nose, mouth, throat

 Itchy ears  Pain on swallowing  Facial weakness


 Chest pain  Irregular heartbeat  High blood pressure


 Wheezing  Cough

Gastrointestinal  Decrease in appetite

Musculoskeletal Skin

 Neck pain  Low back pain  Arm/shoulder pain
 Rash

 Pain  Left  Right  Both

 Discharge/tearing  Left  Right  Both

 Nosebleed  Voice changes  Heartburn

 Loss of smell  Sneezing

 Swelling of ankles/legs  Leg pain with walking  Leg pain with rest

 Shortness of breath  Asthma

 Mucus  Coughing up blood

 Nausea/vomiting

 Difficulty swallowing (food sticks)

 Hip pain  Knee pain  Ankle/foot pain

 Arthritis Name joint(s) :

 Raynaud’s

 Jaundice

Hematologic/ Lymphatic

 Headache
 Insomnia  Other  Depression  Thyroid trouble  Heat/cold intolerance  Anemia

 Seizures  Blackouts

 Paralysis  Tremors

 Medication for Insomnia  Medication for Depression or Other Disorder

 Excessive sweating, thirst, hunger, or urination

 Bleeding problems  Blood disorder (i.e. Sickle cell)

 Easy bruising

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DizzinessAttacksBlood PressureSensationsWeakness