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 • pollackira@sbcglobal.net • http://enfieldneurology.com
Dizziness questionnaire
Name ________________________________ Date _________________________________
If more than one symptom is listed on a line,
□
□
□
□
□
□
□
□
□
□
□
the relevant problem.
Dizziness began: _____ days / weeks / months / years ago
Dizziness began: suddenly / over a few days / gradually
Frequency of dizziness: _____ per week / month / year // most or all the time
Duration of attacks: _____ seconds / minutes / hours // almost constant
Loss of hearing (both ears right ear left ear none)
Pressure / pain / congestion in ear (both ears right ear left ear none )
Dizziness occurs mostly while standing / lying / sitting // any posture
Did you have an attack of fairly severe dizziness lasting 3-7 days at the onset? Y / N
Does the dizziness cause nausea or vomiting? Y / N
Family history of vertigo or hearing loss (who? ____________________________________________)
Dizziness is provoked by:
Movement
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
closing eyes
Exertion
walking
climbing stairs
□
circle
Location
supermarket aisles
wide open spaces
crowded places
high places
closed spaces, elevator
moving background
watching traffic
riding in car / bus
going up / down stairs
Pressure
hearing loud noise
blowing nose
straining on toilet
sneezing
flying in airplane
descending to land
Illness
sinusitis
allergies
stress
fever
menstrual period
headache
pain
weakness in legs
nausea
sense of falling
ringing in ears
hearing loss
shortness of breath
sweating
nausea
headache
palpitation
tingling in fingers or lips
anxiety
loss of balance
stumbling
Dizziness is accompanied by:
spinning sensation
almost fainting
double vision
blurred vision
tunnel vision
bouncing vision
sparkling lights
dim vision
Dizziness 10-07
Page 1 of 2
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 • pollackira@sbcglobal.net • http://enfieldneurology.com
□
Dizziness questionnaire
Current medications for dizziness:
meclizine
Antivert
Plavix
□
stroke
high fever
ear infection
ear surgery
stress
heart surgery
vaccination
change in medication
travel on a boat
Tinnitus (ringing in the ears):
None
Both ears
Right ear
Left ear
Loud
Soft
□
Ativan
Xanax
Sudafed
Dizziness began following:
head injury
fall
car accident
viral infection
meningitis
drug reaction ( to: ___________ )
□
Aspirin
Coumadin
Valium
Constant
Frequent
Occasional
Rare
High tone (“eeeee”)
Low tone (rumble)
Music
Songs
Fixed tone
Pulsatile (whoosh,
whoosh)
Were there any changes in medication around the time the dizziness started?
Y / N __________________________________________________________
Have you ever been treated with intravenous antibiotics, especially gentamicin, tobramycin,
amikacin, streptomycin? Y / N
Have you ever been treated with high dose aspirin?
Does your vision bounce or shake with walking?
Dizziness 10-07
Page 2 of 2