Do you suffer from dizziness and imbalance as a result of a vestibular disorder?

If so, the Ménière’s Society requests your help. Please complete the following survey to help us improve the services we offer and gain a better understanding of your condition and how we can support you.

There are 25 questions. The survey should take no more than 15 minutes to complete.

Many thanks for your time.

1.Which of the following symptoms do you have?

 / Vertigo (dizziness) /  / Tinnitus /  / Hearing Loss /  / Fullness
 / Migraine /  / Balance Problems /  / Drop Attacks

2.For how long have you experienced these symptoms?

 / Less than 6 months /  / Over6 months but less than 1 year. /  / 1 to 2 years /  / 2 to 5 years
 / 5 to 10 years /  / Over 10 years

3.Which vestibular disorder have you been diagnosed with?

 / Benign Paroxysmal Positional Vertigo (BPPV) /  / Endolymphatic Hydrops /  / Labyrinthitis /  / Ménière’s disease/syndrome
 / Migraine Associated Vertigo (MAV) /  / Not diagnosed /  / Other, please state:

4.Who diagnosed your condition?

 / I have not been diagnosed /  / GP /  / ENT Specialist (NHS) /  / ENT Specialist (Private)
 / Other health professional, please state:

5.How long was it between when your symptoms began and when you were diagnosed?

 / Less than a month /  / 1 to 6 months /  / 6 months to 1 year /  / 1 to 2 years
 / Over 2 years /  / I have not been given a diagnosis

6.How long after visiting your GP with your symptoms were you referred to a specialist?

 / Less than 1 month /  / More than 1 month but less than 3 months /  / 3-6 months /  / 6-12 months
 / 1-2 years /  / Over 2 years /  / I have not been referred to a specialist

7.How long did you have to wait between being referred and seeing a specialist?

 / Less than 1 month /  / More than 1 month but less than 3 months /  / 3-6 months /  / 6-12 months
 / Over 12 months

8.Overall, how happy are you with the service you received from your healthcare provider?

Healthcare Provider / Service received
Excellent / Good / Ok / Poor / n/a
GP /  /  /  /  /  /
ENT Specialist - NHS /  /  /  /  /  /
ENT Specialist - Private /  /  /  /  /  /
Audiologist /  /  /  /  /  /
Other Specialist (e.g. Neurologist) - NHS /  /  /  /  /  /
Other Specialist (e.g. Neurologist) - Private /  /  /  /  /  /
Vestibular Physiotherapist /  /  /  /  /  /
Other, please state: ______/  /  /  /  /  /

9.Which of the following tests have you undergone? Please tick all that apply.

 / Audiogram(hearing test) /  / Caloric Test(warm or cold water in ear) /  / CT/CAT Scan(specialised x-rays)
 / Electrocochleograph(measuring electrical activity in the ear) /  / Hallpike Test(lying down quickly and head turned to side) /  / MRI (Magnetic Resonance Imaging) Scan
 / Posturography(computerised balance test) /  / Tympanometry (measures middle ear function) /  / VEMPs(electrical response to sound in the ear measured at the neck or eyes)
 / Other, please state:

10.Which of the following treatments do you use or have usedin the past?

Treatment please tick all that apply / Current / Previously
Betahistine/Serc /  /  /
Prochlorperazine/Stemetil/Buccastem /  /  /
Cinnarizine/Stugeron /  /  /
Diuretics, please state: ______/  /  /
Other medication, please state: ______/  /  /
Vestibular Rehabilitation (balance exercises): Physiotherapist-led /  /  /
Vestibular Rehabilitation (balance exercises): Self-led /  /  /
Hearing aid /  /  /
Bone Anchored Hearing Aid (BAHA) /  /  /
Cochlear implant /  /  /
Meniett Device /  /  /
Self-management /  /  /
Peer support /  /  /
Complementary therapy, please state: ______/  /  /
Other, please state: ______/  /  /

11.Have you had any of the following surgical procedures?

Procedure please tick all that apply / Yes
Grommet /  /
Gentamicin Injection /  /
Steroid Injection /  /
Sacccus decompression/endolymphatic sac surgery /  /
Neurectomy /  /
Labyrinthectomy /  /

12.Does anything trigger your symptoms?

 / No /  / Yes. Please state:

13.Have you made any of the following changes to your diet or lifestyle?

Diet and lifestyle / Yes
Low or no caffeine /  /
Low or no salt /  /
Low or no alcohol /  /
Supplements /  /
Stress management /  /
Taking regular exercise/a physical activity /  /
Other, please state: ______/  /

14.Have you experienced a period of remission?

 / No /  / Yes: Less than 1 month. /  / Yes: More than 1 month but less than 1 year.
 / Yes: 1-2 years /  / Yes: 2-5 years /  / Yes: 5-10 years /  / Yes: Over 10 years

15.Has anyone else in your family been diagnosed with a vestibular disorder?

 / No /  / Yes. If you are happy to, please state their relationship to you and their diagnosis:

16.Have you also been diagnosed with another, non-vestibular,condition?

 / No /  / Yes. If you are happy to, please tell us which condition(s):

17.Are you a member of the Ménière’s Society?

 / Yes, I am a member. /  / I am no longer a member but I was a member in the past. Please tell us why you discontinued your membership:
______/  / No, I am not a member of the Ménière’s Society. Please give your reason for not joining, then go to Q19.

18.What was your reason for joining the Ménière’s Society?

 / To find out more about my condition /  / To see and learn from others’ experiences /  / To receive support material, including Spin magazine /  / To support research
 / Other, please state: ______

19.Is there a peer support group in your area and do you attend the group?

a /  / Yes /  / I attend group meetings /  / I don’t attend the group
b /  / No /  / I would attend if there was a group /  / I wouldn’t attend a group
c /  / Don’t know /  / I would attend if there was a group /  / I wouldn’t attend a group

20.Which Ménière’s Society services have you used, and how would you rate them?

Services
Tick all that apply / Used / Rating
Excellent / Good / Ok / Poor / n/a
Members’ Information Pack /  /  /  /  /  /  /
Spin magazine /  /  /  /  /  /  /
Factsheets and information leaflets /  /  /  /  /  /  /
Telephone information line /  /  /  /  /  /  /
Email enquiries /  /  /  /  /  /  /
Website /  /  /  /  /  /  /
Balance Retraining and Controlling Your Symptoms booklets /  /  /  /  /  /  /
Local Group /  /  /  /  /  /  /
Contact List /  /  /  /  /  /  /
Penpals /  /  /  /  /  /  /
AGM & Conference /  /  /  /  /  /  /
Facebook /  /  /  /  /  /  /
Twitter /  /  /  /  /  /  /
Instagram /  /  /  /  /  /  /
200+ Club /  /  /  /  /  /  /
Christmas Cards /  /  /  /  /  /  /
Christmas Raffle /  /  /  /  /  /  /
Fundraising/Awareness Pack /  /  /  /  /  /  /
Ménière’s Society page on third party websites (e.g. Justgiving, Easyfundraising) /  /  /  /  /  /  /
Other, please state: ______/  /  /  /  /  /

21.Are there any other services in addition to those listed above which you would like us to provide?

22.Are you?

 / Male /  / Female /  / Prefer not to say

23.Age Category

 / 17 or under /  / 18-25 /  / 26-34 /  / 35-49
 / 50-64 /  / 65-79 /  / 80+ /  / Prefer not to say

24.Country of Residence

Please state:

25.Please use this box to add any additional comments:

Thank you very much for taking the time to complete this survey. Your feedback is valued and very much appreciated!

The next page explains how to submit your survey…

How to submit your survey:

By email: Please save your completed form to your computer

Open a new email with Survey 2015 in the subject line

Email your completed survey to

By post:Please print and post your completed survey to to us at:

Meniere’s Society, The Rookery, Surrey Hills Business Park, Wotton, Surrey RH5 6QT.

Results of the survey will be published on the Ménière’s Society website and in our magazine, Spin, in due course.

The following information is optional.

If you would like to receive further information about the Ménière’s Society, please tick this box and provide your name and address details below.

Please also complete your details if you would be happy for us to contact you about your survey responses, should we have any further questions.

Name:
Address:
Email:
Telephone:
Ménière’s Society Membership Number if applicable:

Every so often we’d like to send you information we think may interest you. If you do NOT wish to receive communications from the Meniere’s Society (other than anything requested above), please tick this box 

We take data protection seriously. We will not use any of your information without prior consent. We will never share your information with any third party organisations unless you have provided explicit consent. You can withdraw your consent to be contacted, or amend your permissions, at any time by simply contacting the Ménière’s Society.

Ménière’s Society User Survey 2015 (RCN: 297246) Page 1 of 7