Vestibular clinic questionnaire DRAFT
Bradma lablel
Date: ___/___/____
Relationship status single, married, partnered
Work type:
Which best describes your dizziness/imbalance ?
(Circle as many responses as describe what you experience)
A sensation of movement - yourself or the room (e.g. spinning, tilting)
Lightheadedness or feeling that you are going to faint
A feeling of unsteadiness (e.g. in your head or legs)
Loss of balance
When did the dizziness first occur ?
My dizziness is constant
My dizziness occurs in attacks
These attacks occur
times per day / week / month / year
These attacks last
seconds / minutes / hours / days
What brings on the dizziness or make the dizziness worse ?
What, if anything, makes the dizziness better?
Does your dizziness occur only in certain positions or circumstances (Circle as many
responses as describe what you experience)
When upright
When lying flat
Changes in position of the head or body (e.g. turning over in bed)
Standing up
Quick head movemments
Walking in a dark room
Riding in an elevators
Travelling in an airplane, boat or car
Loud noises Exercise
Coughing, blowing the nose, or straining
Shopping centres, narrow or wide open spaces
When you are "dizzy" do you experience any of the following sensations?
(Circle as many responses as describe what you experience)
Lightheadedness or a ‘swimming’ sensation in the head
Tendency to fall or feel that you may fall
Your surroundings spinning or turning around you
Spinning, tumbling, cart-wheeling, tilting or rocking
Sensation that you are turning or spinning inside
Loss of balance when walking
Blacking out or loss of consciousness
Headache
Pressure in the head
Feeling unclear or ‘whooly’ in the head
Loud noises bother me
Spots before the eyes Nausea or vomiting Bright lights bother me
Do you have any warning that an attack is about to start :
Is there anything which brings the episodes on or worsens them :
Do you suffer with any of the following ? Circle as many responses as describe what you
experience
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Vestibular clinic questionnaire DRAFT
Weakness or numbness in the arms or legs
Blurry or double vision
Tingling around your mouth
Sensation of falling to one side
Other (please specify):
Spots before your eyes
Difficulty with speaking
Are you completely free of dizziness between attacks?
Yes / No
Do you have any of the following? Please circle the ear(s) involved
Difficulty in hearing ?
Noise in your ears ?
Fullness or pressure in your ears?
Right / Left
Right / Left
Right / Left
Past history Please list any medical conditions you have had in the past or have now
Family history Circle any of the following that one or more of your relatives suffer with ?
Dizziness, vertigo, balance or hearing problems
Hearing loss starting at age < 40
Meniere's disease
Convulsions or seizures
Migraine/headaches
Any other diseases that run in the family (please list)
Medications Please list any allergies you have to medications
List your current medications, including any medicines you purchase over the counter at the
pharmacy, health food shop or supermarket:
Investigations Please list any hearing or balance testing that you have had
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