Ear, Nose and Throat Associates of South Florida, P.A.

ENT Hearing Associates of South Florida

Date: ______

Patient Name: ______Label Here

Videonystagmography (VNG) Questionnaire

I. Present illness: I am here because of (circle all that apply):

Dizziness (such as vertigo)

Imbalance

Hearing problem (hearing loss, tinnitus, fullness)

II. Symptoms

My symptoms started on: ______

My symptoms come in: Attacks or are Constant

If in attacks:

How often? ______

How long do they last? ______

Do you have any warning that they are about to start? ______

What? ______

Did you have any illnessat the time of the initial episode? ______

Were you exposed to any irritating fumes, paints, etc. at the onset of the symptoms? ______

Did you have a neck or head injury? ______

Did/do you experience any of the following while dizzy(Place an “X” under applicable response):

YesNo

______1.Spinning or turning, while objects are stationary

If yes, does it occur mostly when you

___lay down ___roll to the right

___roll to the left ___look up on to a shelf

______2.Visual blurring or jumping during head motion

______3.Loss of balance when walking:

___Veering to the right___Veering to the left

______4.Fall(s):

___to the right___forward

___to the left___backward

______5.Swimming sensations in your head

______6.Light-headedness

______7.Blacking out or loss of consciousness

______8.Headache or head pressure

______9.Nausea or vomiting

______10. Other: ______

Patient Name: ______ Label Here

III. Triggers

Are your dizziness, vertigo, imbalance, or hearing problems affected or brought on by:

Yes No Yes No

______1. Changes in position of the head or body ______9. Narrow or wide open spaces

______2. Standing up ______10. Exercise

______3. Rapid head movements ______11. Foods – salt, MSG

______4. Walking in a dark room ______12. Time of day, particular seasons

______5. Elevators ______13. Stress

______6. Airplane, boat, or car travel ______14. Alcohol

______7. Loud noises ______15. Headache/Migraine

______8. Coughing, blowing your nose, or straining ______16. Menstrual periods (if relevant)

______17. Other: ______

IV. Ear Problems

Have you ever had?

  1. Loss of hearing?NoRight Left Both
  2. Abnormal sounds in ear?NoRight Left Both

Describe the noise______

Does it change when you havesymptoms? ______

Does anything make the noise better or worse? ______

  1. Fullness or pressure in ear?NoRight Left Both
  2. Pain in ear?NoRight Left Both
  3. Distortion or sensitivity to sound?NoRight Left Both
  4. Do you use a hearing aid?NoRight Left Both
  5. Noise exposure/trauma?NoRight Left Both
  6. Ear surgery?NoRight Left Both

V. Fall Risk

YesNo

______1. Have you fallen in the past six (6) months?

______2. Have you fallen in the past two (2) years? Amount of falls ______

______3. If you have answered yes to question #2, were you injured in any way (skin tear included)?

______4. Are you worried that you may fall?

______5. Do you have any difficulty rising from a chair?

______6. Do you have any problems with your feet such as pain or numbness?

VI. Other significant history

Please answer the following questions regarding other possible significant history.

YesNo (if yes, please report on onset of symptoms and any current/past treatment)

______1. Allergies? ______

______2. Diabetes? ______

______3. Migraines?

  1. If so, what are your typical symptoms? ______
  2. If so, do you take medication to help w/ symptoms? ______

Patient Name: ______ Label Here

YesNo (if yes, please report on onset of symptoms and any current/past treatment)

______4. Anxiety and/or depression? Past or Present? ______

______5. Tobacco use within the last 24 months? ______

______6. Alcohol use. How much daily/weekly? ______

______7. Caffeine intake(coffee, tea, soda, chocolate,etc.)? How much daily? ______

______8. New glasses? If so, when was last eye exam? ______

______9. High or low blood pressure? If yes, is this presently being managed? ______

______10. Heart disease? ______

______11. Seizure? ______

______12. Memory loss? ______

______13. Difficulty swallowing? ______

______14. Difficulty walking or slurred speech? ______

______15. Weakness of arms or legs? ______

______16. Numbness or tingling of the face or extremities? ______

______17. Body pain. Where & when did symptoms start? ______

______18. Cancer. What type & when? ______

______19. Eye problems (other than glasses)What? ______

20. What sort of work do you do (used to do)? ______

______21. Family history of dizziness, balance, or hearing symptoms? Explain: ______

______22. Other: ______

VII. Previous Studies

YesNo

______1. Ear tests (hearing, ABR, VNG, etc.)? ______

______2. Neurological tests (EEG, cerebral angiogram, carotid Doppler, etc.)? ______

______3. General medical tests (blood tests, EKG, tilt table, etc.)? ______

______4. Scans (x-ray, MRI, CT, etc.)? ______

VIII. Medications

Please list your current medications and why they are taken.

Medications Condition that medication is treating______

______

______

______

______

______

Which medications have you taken in the past 48 hours (prior to VNG testing)?

______

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