Ira Pollack MD, PC
Board certified Neurology, Neurophysiology, Sleep Disorders
1 Corporate Road, Suite 208, • Enfield, CT 06082
(860) 749-5881 • Fax (860) 760-2028 • Neurofax@enfieldsleep.com • http://enfieldneurology.com
Name ________________________________ Date _________________________________
If more than one symptom is listed on a line, circle the relevant problem.
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Dizziness began: _____ days / weeks / months / years ago
Frequency of dizziness: _____ per week / month / year // most or all the time
Duration of attacks: _____ minutes / hours
Loss of hearing (both ears right ear left ear)
Pressure / pain / congestion in ear (both ears right ear left ear)
Dizziness occurs while standing / lying / sitting / any posture
Did you have an attack of fairly severe dizziness lasting 3-7 days at the onset? Y / N
Nausea
Family history of vertigo ( who? ___________
______________________________)
Dizziness is provoked by: turning head rolling in bed to right rolling in bed to left looking up reaching to high shelf bending over standing up getting out of bed
Dizziness is accompanied by: spinning sensation double vision blurred vision tunnel vision sparkling lights dim vision weakness in legs walking climbing stairs hearing loud noise blowing nose straining on toilet sneezing menstrual period flying in airplane nausea sense of falling ringing in ears hearing loss shortness of breath sweating nausea descending to land sinusitis allergies stress fever headache pain closing eyes headache palpitation tingling in fingers tingling of lips anxiety loss of balance stumbling
□ Current medications for dizziness: meclizine
Antivert
Plavix
Aspirin
Coumadin
Valium
Ativan
Xanax
Sudafed
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Ira Pollack MD, PC
Board certified Neurology, Neurophysiology, Sleep Disorders
1 Corporate Road, Suite 208, • Enfield, CT 06082
(860) 749-5881 • Fax (860) 760-2028 • Neurofax@enfieldsleep.com • http://enfieldneurology.com
Dizziness began following: head injury fall car accident viral infection drug reaction ( to: _________ )
Tinnitus (ringing in the ears):
None
Both ears
Right ear
Left ear
Loud
Soft meningitis stroke high fever ear infection
Constant
Frequent
Occasional
Rare
High tone (“eeeee”)
Low tone (rumble) ear surgery heart surgery vaccination
Music
Songs
Fixed tone
Pulsatile (whoosh, whoosh)
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