Then check yes or no to describe your feelings most accurately. |
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Lightheadedness or swimming sensation in the head |
Yes |
No |
Tendency to fall: To the right? |
Yes |
No |
Tendency to fall: To the left? |
Yes |
No |
Tendency to fall: Forward? |
Yes |
No |
Tendency to fall: Backward? |
Yes |
No |
Objects spinning or turning around you. |
Yes |
No |
Sensation that you are turning or spinning inside, with outside objects remaining stationary. |
Yes |
No |
Sensation of the environment moving up and down while you walk. |
Yes |
No |
Loss of balance when walking: Veering to the right? |
Yes |
No |
Veering to the left? |
Yes |
No |
Headache. |
Yes |
No |
Nausea or vomiting |
Yes |
No |
Pressure in the head. |
Yes |
No |
Palpitations, perspiration, shortness of breath, or a feeling of panic. |
Yes |
No |
|
Please check yes or no and fill in the blank spaces. Answer all questions. |
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My dizziness is: Constant? |
Yes |
No |
My dizziness is: In attacks? |
Yes |
No |
When did dizziness first occur? |
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|
If in attacks: How often? |
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How long do they last? |
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When was the last attack? |
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Do you have any warning that the attack is about to start? |
Yes |
No |
Do they occur at any particular time of day or night? |
Yes |
No |
Are you completely free of dizziness between attacks? |
Yes |
No |
Does change of position make you dizzy? |
Yes |
No |
Do you have trouble walking in the dark? |
Yes |
No |
When you are dizzy, must you support yourself when standing? |
Yes |
No |
Do you know of any possible cause of your dizziness? |
Yes |
No |
|
Do you know of anything that will:Stop your dizziness or make it better? |
Yes |
No |
|
Make your dizziness worse? |
Yes |
No |
Precipitate an attack? |
Yes |
No |
Were you exposed to any irritating fumes, paints, etc., at the onset of dizziness? |
Yes |
No |
|
If you are allergic to any medications? |
Yes |
No |
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Do you use tobacco in any form? |
Yes |
No |
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Do you have any of the following symptoms? Please check yes or no and check ear involved. |
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Difficult in hearing? |
Yes |
No |
|
Noise in your ears? |
Yes |
No |
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How loud is your tinnitus or head noise most of the time? |
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Describe the noise |
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Does noise change with dizziness? If so, how? |
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Fullness of stuffiness in your ears? |
Yes |
No |
|
Pain in your ears? |
Yes |
No |
|
Discharge from your ears? |
Yes |
No |
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Have you ever experienced any of the following symptoms? Please check yes or no and check constant or in episodes. |
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|
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Double Vision, blurred vision or blindness |
Yes |
No |
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Numbness of face. |
Yes |
No |
|
Numbness of arms or legs. |
Yes |
No |
|
Weakness in arms or legs. |
Yes |
No |
|
Clumsiness of arms or legs. |
Yes |
No |
|
Confusion of loss of consciousness. |
Yes |
No |
|
Difficulty with speech. |
Yes |
No |
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Difficulty with swallowing. |
Yes |
No |
|
Pain in the neck or shoulder. |
Yes |
No |
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Seasickness or car sickness |
Yes |
No |
|