8/10/2019 ENG VRT Questionnaire

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Questionnaire

Patient Name: ____________________________ Birthdate: __________ Sex: M / F Date:__________

Primary Care Physician: ____________________ Referring Physician:_________________________

Equii!rium dis"rders #resent $ith a %ariety "f sym#t"ms that are different f"r each #ers"n& S"me #e"#e mayex#erience di''iness and %ertig" $hie "thers are unsteady and "ff(!aance& Please take your time in filling out

the questionnaire to the best of your ability& )hese questi"ns are designed t" "!tain the m"st accurate

inf"rmati"n a!"ut y"ur sym#t"ms&

*"$ and/"r $hen did y"ur #r"!em first "ccur+___________________________________________________

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,& D" y"u ex#erience any "f the f""$ing sensati"ns+ Circe -ES "r N. t" descri!e y"ur feeings&

-ES N. Fee ie y"u are s#inning in circes inside $hie the $"rd stays

stati"nary+-ES N. Faing t" "ne side+ $hich side+ ______________________________

-ES N. Fee as th"ugh the $"rd is s#inning ar"und y"u+

,,& ,f y"u ha%e di''iness0 #ease circe -ES "r N. and fi in the s#aces $ith additi"na inf"rmati"n&

-ES N. 1re y"ur di''y s#es c"nstant+

-ES N. D" y"ur di''y s#es c"me in attacs+ ,f -ES0 h"$ "ften+ ___________ *"$ "ng d" they ast+ _______________________

Date "f first s#e+ ___________________________

-ES N. 1re y"u c"m#etey free fr"m di''iness in !et$een attacs+-ES N. D" y"u ha%e any $arning signs !ef"re an attac+

,f -ES0 $hat+ ______________________________________________

-ES N. D"es y"ur hearing change $ith an attac+

-ES N. ,s the di''iness #r"%"ed !y any #articuar head/!"dy m"%ement+,f -ES0 descri!e_____________________________________________

-ES N. 1re y"u di''y $hen y"u sit u#0 ie d"$n0 "r stand u# t" quicy+ 2circe

any that a##y3+-ES N. ,s the di''iness !etter "r $"rse at any #articuar time "f day+

,f -ES0 $hen+ ______________________________________________

-ES N. 1re y"u nauseated "r d" y"u %"mit during an attac+-ES N. ,s there anything that y"u can d" t" st"# the di''iness+

,f -ES0 $hat+ ______________________________________________

-ES N. Can y"u #r"%"e the di''iness+,f -ES0 h"$+ ______________________________________________

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