Information and Instructions for Patients
Electronystagmography (ENG) Testing
This is a test to see how well your Balance system is transmitting information to your brain. We do this by
sticking some electrode pads around your eyes and forehead. During part of the test you will be sitting on an
examination table and watching some red lights move in different directions. Another part of the test you
will be placed in different positions on an examination table (sitting and lying down). Some even become
nauseated. If this happens to you we will stop the testing, at your request, or by using our own judgment.
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If you have any joint or spinal problems you need to inform the Examiner prior to the test session.
We will also need a referral from your physician prior to the test.
Ask your physician if any of your medications will affect our test results.
Do not take any tranquilizers, sedatives or vestibular suppressants for at least 48 hours before your
test.
 Do not drink alcoholic beverages or caffeine for at least 48 hours before your test.
 If the test is in the morning, do not eat breakfast, or if the test is in the afternoon, do not eat lunch.
 Women should wear slacks.
It will be necessary to clean your skin where we place the electrode pads. Therefore, we ask you not to use
hairspray or makeup. Because the skin must be very clean we use a gel that contains a special material that
feels like sand and an alcohol pad. This removes any dead skin and helps the electrodes to conduct
information better. You may find that your skin might be red and somewhat tender at the spots where we
cleaned. Although it is rare, it is possible that some individuals may have an allergic reaction to the electrode
gel. If any abnormal symptoms occur, please call the office immediately.
I have read the above. I have had all my questions answered and I understand the procedure, its benefits and
potential risks. I freely give my consent for the testing of myself or my minor child.
Patient’s Name _____________________________________________
Date _________________________
Parent or Guardian’s Name for Minor __________________________
Examiner’s Signature ________________________________________
Date _________________________
Name ____________________________ Age ______________ Sex ___________ Date ___________________
The following questions refer to you feeling of dizziness. Please answer them “yes” or “no” and fill in all blanks.
1.
Please describe, in your own words, the sensation you feel. ___________________________________
____________________________________________________________________________________
2.
3.
Do you ever have any of the following sensations:
Spinning in circles?
Yes
No
Falling to one side?
Yes
No
World spinning around you?
Yes
No
Yes
No
Does your hearing change with an attack?
Yes
No
Are you dizzier in certain positions?
Yes
No
Are you nauseated during an attack?
Yes
No
Had a recent cold or flu preceding recent
dizzy spells?
Yes
No
Pain or discharge in your ear of recent onset?
Yes
No
Are you better if you sit or lie perfectly still?
Yes
No
Do you black out or faint when you are dizzy?
Yes
No
Are you dizzy or unsteady constantly?
Yes
No
Do you have severe or recurrent headaches?
Yes
No
Any double or blurry vision?
Yes
No
Numbness in your face or extremities?
Yes
No
Spots before your eyes?
Yes
No
Yes
No
The following refer to a typical dizzy spell:
Does the dizzy spells come in attacks?
How Often? _________________________
How Long? _________________________
Which position? _____________________
4.
5.
The following refer to other sensations you may have:
The following refer to your hearing:
Difficulty hearing in 1 ear?
Ringing in 1 ear?
Yes
No
Did ringing start before dizziness?
Yes
No
Fullness in 1 ear?
Yes
No
Change in hearing when dizzy?
Yes
How? _____________________________________________________
Exposure to loud noises?
Yes
No
No
Previous ear infections?
Yes
No
Previous ear surgery?
Yes
No
What? ______________________________ When? ________________
Family history of deafness from
R___
R___
L___
R___
L___
R___
L___
L___
6.
childhood or onset in early adulthood?
Yes
No
Pain in ears?
Yes
No
R___
L___
Discharge from ears?
Yes
No
R___
L___
Perforation in your ear/ears?
Yes
No
R___
L___
The following refer to habits and lifestyle:
Is there added stress in your life recently?
7.
8.
Yes
No
Is your dizziness related to:
Moments of stress?
Yes
No
Menstrual period?
Yes
No
Overwork or exertion?
Yes
No
Did you recently change eyeglasses?
Yes
No
Do you drink coffee?
Yes
No
How much? _____________________
Do you drink alcohol?
Yes
No
How much? _____________________
Do you smoke?
Yes
No
How much? _____________________
Medical History: Please list your current medical problems and length of illness?
_____________________________________________________________________________
_____________________________________________________________________________
9.
Medications: Please list all medications you are currently take (including pain medication, nonprescription
medications, and/or sleeping pills). _____________________________________________________
______________________________________________________________________________
______________________________________________________________________________
10. Miscellaneous:
Are you allergic to any medications?
Yes
No
High blood pressure?
Yes
No
Low blood pressure?
Yes
No
Diabetes?
Yes
No
Low blood sugar?
Yes
No
Thyroid disease?
Yes
No
Asthma?
Yes
No
Any eye surgery?
Yes
No
Any head injury?
Yes
No
11. Do you have anything else to tell us about your particular problem that we haven’t
asked you on this questionnaire?______________________________________________
_________________________________________________________________________
_________________________________________________________________________
__________________________________________
Patient Signature
____________________
Date