VERTIGO (Dizziness)

Please correct the errors described below.

Name:

Date

We are interested in your illness and would like to find out more. Please fill this out to the best of your knowledge. If you do not know the exact dates and duration, please estimate.

1. Do you have seasonal or food allergies?

No Yes

If yes, Please list:

2. Please write the first date you experienced dizziness:

3. What did it feel like the first time you were dizzy? Select all that apply:

Nausea

Passing out

Vomiting

Light Headed

Ringing in the Ear(s)

Clouded Thoughts

Headache

Head Fullness

Spinning

Ear fullness

4. How long did the first episode last? (1min, 10 min, 1 hour,1 day, 1week)

5. Was there any hearing change during the first episode or afterwards?

No Yes

If yes, how did it change?

6. Please select how often/ frequently you are experiencing dizziness NOW:

Daily Weekly Every Month Every 6 Months Every Year

7. What is happening to your dizziness? (circle one)

It is the same It is improving It is worsening

8. Are you able to tell when dizziness is about to happen (are there warning signs)?

No Yes

If yes, what is the sign?

9. Have you ever had ear surgery?

No Yes

If yes, what kind?

10.Have you ever had ear infections?

No Yes

If yes, when?

11.Have you ever had any problems with your eyes?

No Yes

If yes, what kind?

12.Have you been diagnosed with migraines?

No Yes

If yes, what kind?

13.Have you had any scans (images) of your brain?

No Yes

If yes, what kind?

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