HISTORY AND PHYSICAL FOR DIZZINESS
James R. Carlson, M.D., M.B.A.
David H. Zacheis, M.D., FACS
Matthew J. Clavenna, M.D.
Stephanie Carlson, R.N., CNOR
Erica M. Hansen, Au.D., F-AAA
Abby L. McClelland, Au.D.
Name: ________________________________ Date:________________ Age:__________________
Brief History of dizziness: ____________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Onset: _______________________________ Frequency: ___________________________________
Duration of spells:
seconds
Symptoms (circle):
nausea
staggering (right/left)
light headed
Positional Correlation (circle):
Hearing loss? __________
Tinnitus? _____________
Fullness in ears? _______
minutes
hours
days
constant
vomiting
cold sweats
falling
lying flat
fast movement
room spinning
passing out
constant/intermittent
turning in bed (right/left)
looking up/down
Which ear? _____________ Steady or fluctuant? ___________________
Which ear? _____________ Steady or fluctuant? ___________________
Which ear? _____________ Steady or fluctuant? ___________________
Previous testing or X-rays? _____________________________________________________________
Previous diagnosis? ___________________________________________________________________
Previous treatment for dizziness?__________________________ by Doctor_______________________
General history (please circle those that apply):
heart
hypertension
hypotension
circulation
anemia
diabetes
slurred speech
blurred vision
stroke
confusion
loss of consciousness
high cholesterol
Physician Use Only:
Neuro-Otological Examination:
Romberg:
Cerebellar:
Sharpened
Tandem
Tandem Sharpened
Cranial N VII-XII:
ear injury
head injury
anxiety
nicotine
alcohol
caffeine
EOM: Gaze nystagmus
Finger to nose
Rapid alternating motion
Eyebrow raise
Eye squeeze
Smile symmetry
Cheek puff
POSITIONAL TEST: Right Left
Shoulder shrug
Nystagmus: Horizontal Rotary Fatigable Latent
Tongue symmetry
Gag reflex
AUDIOGRAM Results: Normal
Sensorineural loss Conductive loss Right Left
VNG Results: BPPV Central Peripheral Right Left Cervical Vestibular Ocular Reflex
MRI/CT Results :