QUESTIONS: (Please check

YES

NO

1.Describe your dizziness (choose one of more of the following), primary 5 symptoms.

a)      Objects spinning

b)      Head spinning

c)      Light headed no spinning

d)      Swimming sensation in head

e)      Blackouts

f)        Seeing stars of lights

g)      Mainly unsteady walking

h)      Trouble with balance (i.e. giddy, feeling like I’m going to fall)

i)        Lightheaded

j)        Feeling like objects around me are spinning or turning

k)      Feeling like I’m spinning or turning but objects around me are not

l)        Tilting or leaning

m)   Headache

n)      Nausea

o)      Vomiting

p)      Tendency to veer to the left when walking in the dark

q)      Tendency to veer to the right when walking in the dark

r)       Feeling of pressure in my head

s)      Feeling of pressure in ear(s)

t)        Tingling in my hands or toes or around my mouth

u)      Loss of consciousness

v)      Giddy feeling like I’m going to fall

TIME OF ONSET AND CONTRIBUTING FACTORS

2. Does your dizziness occur in attacks or episodes?

a)      How often do you have dizzy spells?

b)      Is the dizziness there all the time?

3. When did you first experience feelings of dizziness?

4. How long do the spells last?

5. How do you feel in between your dizzy spells?

6. Do the dizzy spells occur at a particular time of day?

7. Do any of the following make your dizziness worse or trigger it?

a)      Hunger

b)      Menstrual period

c)      Bending your head forward or backward

d)      Turning your head to either side

e)      Coughing

f)        Bowel movement

g)      Stress

h)      Fatigue

i)        Drinking alcohol

j)        Flying

k)      Driving or riding in a moving vehicle

l)        Heights (e.g., looking down from a balcony or a window in a high-rise building)

m)   Ingesting caffeine (including coffee, tea, colas, chocolate)

n)      Using tobacco

o)      Using any particular medication (over-the-counter and prescription)

8. About your dizziness attacks:

a)      Date of your first dizziness attack:

b)      How long did it last?

c)      Are your attacks now similar to the first one?

Is spinning brought on by:

a)      Standing

b)      Changing positions

c)      Lying to sitting

d)      Sitting to standing

e)      Looking up

f)        Rolling to the left in bed

g)      Rolling to the right in bed

h)      Not known

What makes your dizziness better?

Are the attacks becoming more severe?

How many major attacks have you had in the past 6 months?

How many minor attacks have you had in the past 6 months?

9. If your dizziness is mainly unsteadiness:

a)      Does it occur only while walking?

b)      Does it occur while lying down?

c)      What makes unsteadiness better?

d)      Does it occur in episodes?

e)      Is it present all of the time?

f)        Does is occur when getting out of bed?

g)      Does it occur when getting up quickly?

h)      Is it getting worse?

10. Do you have loss of consciousness?

a)      Double vision?

b)      If yes, constantly?                            Or at times?

c)      Numbness of the face?

d)      Clumsiness of the arms?

e)      Difficulty in speech?

11. Are you disabled by your dizziness?

If yes: please answer

a)      Can you work in a physical job?

b)      Can you work in a hazardous job?

c)      Can you work at a sitting job?

d)      Are you able to work at all?

12. Do you have different types of dizzy spells?

If yes, please describe:

ASSOCIATED SYMPTOMS

13. Do you have hearing loss?

a)      In one ear?

b)      In both ears?

If yes, which is worse (please circle)          RIGHT or LEFT

c)      Does your hearing fluctuate (go up and down)?

If yes, which ear? (please circle)                 RIGHT or LEFT

d)      Do you get noise or ringing in your ear?

If yes, which ear?                                        RIGHT or LEFT

If yes, does this increase while you are feeling dizzy?

e)      Do you have pressure or fullness in your ear

If yes, does this increase while you are feeling dizzy?

f)        Blurred vision

g)      Double vision

h)      Numbness in the face or extremities

i)        Loss of consciousness

j)        Difficulty swallowing

14. Is there a family history of dizziness or hearing loss?

If yes, please describe:

15. Have you ever been exposed to loud noises?

16. Have you ever had IV (intravenous) antibiotics?

17. Were you in an accident before the dizziness started?

       If yes: Type of accident:_______________________________________ Date:_____________________________________________________________________________________________________________________________________________________________________________________________

RELEVANT MEDICAL HISTORY

18. Do you have any food allergies? (Describe; include airborne, food, drug, etc.)__________________________________________________________

____________________________________________________________________________________________________________________________

19. Have you ever had a head injury? (Explain; include at what age(s) and severity.)___________________________________________________________________________________________________________________________________________________________________________________

20. Did you have earaches or ear infections as a child?

21. Did you suffer with motion sickness before the age of 12?    

22. Have you experienced motion sickness within the last 10 years?

23. Do you have diabetes?  High blood pressure?  Kidney disease?  Thyroid disease?  Bout of migraine?  Heart disease?

24. Do you have a family history of diabetes?  Ear disease?  Neurological disease (e.g., multiple sclerosis or Parkinson’s disease)?  Migraine?