Questionnaire
Patient Name: ____________________________ Birthdate: __________ Sex: M / F Date:__________
Primary Care Physician: ____________________ Referring Physician:_________________________
Equilibrium disorders present with a variety of symptoms that are different for each person. Some people may
experience dizziness and vertigo while others are unsteady and off-balance. Please take your time in filling out
the questionnaire to the best of your ability. These questions are designed to obtain the most accurate
information about your symptoms.
How and/or when did your problem first occur?___________________________________________________
________________________________________________________________________
________________________________________________________________________
I. Do you experience any of the following sensations? Circle YES or NO to describe your feelings.
YES
NO
YES
YES
NO
NO
Feel like you are spinning in circles inside while the world stays
stationary?
Falling to one side? which side? ______________________________
Feel as though the world is spinning around you?
II. If you have dizziness, please circle YES or NO and fill in the spaces with additional information.
YES
YES
NO
NO
YES
YES
NO
NO
YES
YES
NO
NO
YES
NO
YES
NO
YES
YES
NO
NO
YES
NO
Are your dizzy spells constant?
Do your dizzy spells come in attacks? If YES, how often? ___________
How long do they last? _______________________
Date of first spell? ___________________________
Are you completely free from dizziness in between attacks?
Do you have any warning signs before an attack?
If YES, what? ______________________________________________
Does your hearing change with an attack?
Is the dizziness provoked by any particular head/body movement?
If YES, describe_____________________________________________
Are you dizzy when you sit up, lie down, or stand up to quickly? (circle
any that apply)?
Is the dizziness better or worse at any particular time of day?
If YES, when? ______________________________________________
Are you nauseated or do you vomit during an attack?
Is there anything that you can do to stop the dizziness?
If YES, what? ______________________________________________
Can you provoke the dizziness?
If YES, how? ______________________________________________
_____________________________________________________________________________________
3860 South Lindbergh Boulevard, #108 St. Louis, Missouri 63127
phone 314-729-0077
fax 314-729-01011 website www.soundhealthservices.com
YES
NO
YES
YES
NO
NO
YES
YES
YES
NO
NO
NO
YES
NO
Do you know of any possible cause of your dizziness?
If YES, what? ______________________________________________
Have you had a recent cold or flu preceding your recent dizzy spells?
Have you had fullness, pressure, or ringing in your ears? (circle)
If YES, circle which ear: Right, Left, Both
Do you have trouble walking in the dark?
Are you better if you lie down or sit perfectly still?
Do you have loss of balance when walking?
If YES, do you veer to the right or left? ________________
Do you have problems walking in the grocery store, narrow or wide
spaces?
III. The following questions refer to other sensations you may have. Please circle YES or NO.
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Do you black out or faint when dizzy?
Do you have lightheadedness?
Severe or Recurrent Headaches?
Migraines?
Recent onset or for many years? (circle one)
Numbness in your face, arms, legs?
Constant
In Episodes
Weakness/Clumsiness in arms or legs?
Constant
In Episodes
Confusion or loss of consciousness
Constant
In Episodes
Slurred or difficult speech?
Constant
In Episodes
Jerking of the arms or legs?
Constant
In Episodes
Difficulty Swallowing
Constant
In Episodes
Tingling around your mouth
Constant
In Episodes
Have you had a recent head trauma?
IV. Do you have any of the following symptoms related to your HEARING? Circle YES or NO.
YES
NO
Difficulty hearing? (circle one) Both Ears Right Ear
Left Ear
When did this start?_________________________________________
Was it sudden or gradual (circle one)?
YES
NO
Do you feel like your hearing is getting worse?
YES
NO
Do you have ringing or buzzing in your ears?
If YES, circle one
Both Ears
Right Ear
Left Ear
Is the noise constant or episodic? (circle one)
YES
NO
Does the noise change with your symptoms?
If YES, describe _____________________________________________
YES
NO
Does anything stop the noise or make it go away temporarily?
If YES, what? ______________________________________________
YES
NO
Do you have fullness or stiffness in your ears?
If YES, circle one
Both Ears
Right Ear
Left Ears
Does this change when you are dizzy? ___________________________
YES
NO
Do you have any pain in your ears?
If YES, circle one
Both Ears
Right Ear
Left Ear
_____________________________________________________________________________________
3860 South Lindbergh Boulevard, #108 St. Louis, Missouri 63127
phone 314-729-0077
fax 314-729-01012 website www.soundhealthservices.com
YES
NO
YES
YES
NO
NO
YES
YES
NO
NO
Do you have any discharge from your ears?
If YES, circle one
Both Ears
Right Ear
Left Ear
Have you had exposure to loud noises?
Have you ever had ear surgery?
If YES, when and what type? __________________________________
Are you prone to ear infections?
Do you have a family history of deafness and/or hearing loss?
V. Medical History – Past and Present. Please circle all that affect you.
Constitutional : Weight loss (15 lbs or more)
Cardiovascular: Anemia
Fainting
High Blood Pressure
Trouble sleeping
Heart Problems
High Cholesterol
Low Blood Pressure Diabetes
Palpitations
Cancer: Type? __________________________ When? ___________________________
Endocrine:
Low sugar (hypoglycemia)
Thyroid Disorder
Psychological: Depression Unusual amounts of stress
Pain: Arthritis
Pain in back of jaw (TMJ)
Back pain
Treatment by psychiatrist/counselor
Migraine, Sinus, or Tension headaches
Neck Pain
Immunologic: Allergies? __________________________________________________
Lupus or other autoimmune diseases? ___________________________________
Breathing Problems: Asthma
Pneumonia
Sinusitis
Stomach Problems: Ulcer
Reflux
Irritable Bowel
Eye Problems: Crossed Eye
Lazy Eye
Cataracts
Blurred Vision
Double Vision
Neurological Problems: Vitamin B12 Deficiency
Meningitis
Multiple Sclerosis
Muscle, Paralysis, or weakness
Deviated Septum
Macular Degeneration
Detached Retinas
Carpal Tunnel
Memory Loss
Pins, Needles, Numbness
Speech Disturbance
Spots before eyes
Seizures
Tremors
_____________________________________________________________________________________
3860 South Lindbergh Boulevard, #108 St. Louis, Missouri 63127
phone 314-729-0077
fax 314-729-01013 website www.soundhealthservices.com
List any surgeries and dates: _________________________________________________________
VI. Medications
What are your current medications? Include everything.
1.________________________________________2._______________________________________3.______
__________________________________4._______________________________________5.______________
__________________________6._______________________________________7.______________________
__________________8._______________________________________
What medications have you taken for your current problem of dizziness/vertigo/or disequilibrium?
1. ______________________________________ 2.____________________________________
3._______________________________________ 4.____________________________________
Have you ever taken any of the following drugs? (circle all that you have taken)
Aspirin in large doses
Quinidine (for malaria)
Cisplatin (for cancer)
Streptomycin (antibiotic)
Furosemide (Lasix)
Tamoxifen (to prevent breast cancer)
Gentamicin (antibiotic)
Tobramycin (antibiotic)
Kanamycin (antibiotic)
Vancomycin (antibiotic)
Malaria Drugs (quinine)
Procardia (for blood pressure)
VII. The last section refers to your lifestyle and habits. Please answer to the best of your ability.
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
Do you drink caffeinated beverages?
How much? ____________
Do you smoke?
How much? ____________
Do you drink alcohol?
How much? ____________
Did you recently change eyeglasses?
Do you exercise?
How often? ____________
Do you have a lot of stress in your life?
Do you notice dizziness during:
Moments of stress?
Menstruation?
Overwork or Exertion?
Do you have weakness or faintness if you haven’t eaten for a few hours?
During plane, automobile, train rides?
Please tell us anything else relevant to your health that we may not have asked you on this questionnaire.
_____________________________________________________________________________________
3860 South Lindbergh Boulevard, #108 St. Louis, Missouri 63127
phone 314-729-0077
fax 314-729-01014 website www.soundhealthservices.com