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8/10/2019 chestionar vertij utilizat
1/2
ANDREW MARLOWE, MD, PA
Otolaryngology
Vertigo/Dizziness/Imbalance Questionnaire
NAME: _______________________________________ DATE: _____________________
Please understand that the following questions are difficult to answer and vague. Dizziness is a very
difficult problem to diagnose and this form is an important part of your care.
A. When you are dizzy do you experience any of the following sensations? Please read the entire list, then check
yes or no to describe your feelings most accurately.
1. Lightheadedness or swimming sensation in the head YES NO
2. Near blacking out or loss of consciousness YES NO
3. Tendency to fall:
To the right? YES NO Forward? YES NO
To the left? YES NO Backward? YES NO
4. Objects spinning or turning around you YES NO
5. Sensation that you are spinning inside, with outside objects remaining stationary YES NO
6. Loss of balance when walking YES NO
7. Headache YES NO
8. Nausea or vomiting YES NO
B. Please try to answer all questions. Circle yes or no and fill in the blank spaces.
1. My dizziness is:
Constant? YES NOIn attacks? YES NO
2. When did dizziness first occur (very first episode ever)?
3. If in attacks: How Often? ______________________________________________________________
How long do they last? ___________________________________________________________
When was the last attack? _________________________________________________________
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
4. Does change of position make you dizzy? YES NO
5. Do you have trouble walking in the dark? YES NO
6. When you are dizzy, must you support yourself when standing? YES NO
7. Do you know of any possible cause of your dizziness? YES NO
What? _________________________________________________________________________
8/10/2019 chestionar vertij utilizat
2/2
ANDREW MARLOWE, MD, PA
Otolaryngology
Vertigo/Dizziness/Imbalance Questionnaire
8. Do you know of anything that will: (fatigue? Exertion? Hunger? Menstrual Period? Stress?)
Stop your dizziness or make it better? YES NO
Make your dizziness worse? YES NO
Precipitate an attack? YES NO
9. Is there anything about your dizziness that makes you think that it is coming from your ears?
What? _________________________________________________________________________
10. Do you have any blood relatives with dizziness or ear problems? YES NO
Who? _________________________________________________________________________
What problem? __________________________________________________________________
11. Did you ever injure your head? YES NO
Were you unconscious? YES NO
When was your injury? ___________________________________________________________
12. Have you been on any medications to help the dizziness? YES NO
Which? ________________________________________________________________________Did they help? YES NO
13. Do you use tobacco in any form? YES NO
14. Do you have poor circulation? YES NO
15. Do you have diabetes? YES NO
16. Do you have trouble with vision? YES NO
17. Are your feet or toes numb? YES NO
9.
Do you have any of the following ear symptoms? Please circle yes or no and the ear involved.
1. Difficulty in hearing? NO YES BOTH EARS RIGHT EAR LEFT EAR
2. Stuffiness or pressure in ears? NO YES BOTH EARS RIGHT EAR LEFT EAR
3. Pain in ears? NO YES BOTH EARS RIGHT EAR LEFT EAR
4. Fluid from ears? NO YES BOTH EARS RIGHT EAR LEFT EAR
5. Noise in ears or head?** NO YES BOTH EARS RIGHT EAR LEFT EAR
6. Does the noise change with the
dizziness? NO YES
** If you have noise in ears or head, please ask for and fill out a Tinnitus Questionnaire.
10. Have you ever experienced any of the following symptoms?
1. Double, blurred or loss of vision? NO YES CONSTANT EPISODES2. Numbness of face, arms or legs? NO YES CONSTANT EPISODES
3. Weakness in arms or legs? NO YES CONSTANT EPISODES
4. Clumsiness in arms or legs? NO YES CONSTANT EPISODES
5. Confusion or loss of consciousness? NO YES CONSTANT EPISODES
6. Difficulty with speech? NO YES CONSTANT EPISODES
7. Difficulty with swallowing? NO YES CONSTANT EPISODES8. Pain in neck or shoulder? NO YES CONSTANT EPISODES