Patient Name______Date______

  1. When did yoursymptoms begin?______
  1. Describe what you are experiencing.

Spinning/Rotation(Vertigo)Lightheaded Off Balance Passing out/fainting

Drunk feeling(Ataxia)Other: ______

  1. How long do your symptoms last?______

Few seconds Seconds to minutesMinutes to several hours

Hours to daysContinuousOther______

  1. How many episodes of Vertigo have you had?

Single Multiple Never had vertigo

  1. What things have been associated with your episodes?

Altered head positions Rapid Ascents Neck extension Salty Foods Headaches

Loudsounds Changes in ear pressure Rolling over in Bed Migraines Pain Stress

  1. What other symptoms do you get around the time of dizzy attacks?

Hearing loss Tinnitus Aural fullness Headaches Facial numbnessAnxiety Nausea/vomiting Change in vision Muscle weakness Pain Other______

  1. I have the following medical problems.

DiabetesStrokes HBPCardiovascular Back/Neck Problems Ear surgery

Visual difficulty Seizures Migraines MS Anxiety/Depression Cancer Motion sickness

  1. Are there any activities you are unable to do because of your symptoms? ______

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  1. Have the symptoms changed since the first episode? Yes No

If yes:Better Worse Shorter Longer More severe Less severe

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QUESTION 10 IS ONLY ANSWERED BY PATIENTS RECEIVING A VNG - PLEASE ASK THE FRONT DESK IF YOU NEED TO COMPLETE QUESTION 10.

  1. What substanceshave you had?

In the last 36 hours:

  • Antidizziness meds (Meclizine, Antivert, Bonine, Dramamine, Etc.)
  • Allergy or Cold medications that cause drowsiness (Benadryl, Diphenhydramine, Sominex, Etc.)
  • Klonapin (Klonazapam). Is this taken for seizures? Yes / No
  • Antianxiety meds (Xanex, Alprazolam, Etc.).

How long have you been taking this at a stable dose? ______

  • Prescription pain pills (Tylenol 3, Vicodin, Etc.)

How long have you been taking this at a stable dose? ______

  • Benzodiazepines (Valium Ativan, Etc.)

How long have you been taking this at a stable dose? ______

  • Anti-depressants (Prozac, Lexapro, Wellbutrin, Etc.)

How long have you been taking this at a stable dose? ______

  • Anti-nausea meds (Promethazine, Compazine, Zofran, Etc.)
  • Ambien

In the last 24 hours:

  • Alcohol

In the last 8 hours:

  • Sleeping medications

In the last 4 hours:

  • Caffeinated items, such as coffee, tea, soda, energy drinks
  • Items with nicotine

This questionnaire was completed by:

______

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Relationship to patient if not completed by patient