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DIZZY EVALUATION FORM
Please complete prior to your appointment.
Dizzy Evaluation
First Name
*
Last Name
*
Email
*
Phone
Date
MM slash DD slash YYYY
Is your dizziness constant or does it come in spells? (pick one)
*
It is constant
It comes in spells
If it comes in spells, my dizzy attack lasts (pick one)
*
Minutes
Hours
Days
Weeks
Varies greatly
Usually, an attack happens (pick one)
*
Less than once a month
At least once a month
At least once a day
Daily
Varies greatly
Does change of position make you dizzy?
*
Yes
No
Do you know anything that will cause an attack?
*
Yes
No
If yes, please explain
*
Do you know anything that will stop your dizziness or make it better?
*
Yes
No
If yes, please explain
*
Do you know anything that will make your dizziness worse?
*
Yes
No
If yes, please explain
*
When dizzy do you experience any of the following?
*
Lightheadedness
Objects spinning around you
Tendency to fall
Loss of balance when walking
Headache
Nausea or vomiting
Pressure in the head
If yes, to tendency to fall, please explain in which way
*
If yes, to loss of balance to walking, please explain. Do you lose balance on right or left?
*
Do you experience any of the following? (check all that apply)
Difficulty in hearing
*
Yes
No
In both ears
Right ear
Left ear
Does your hearing fluctuate
*
Yes
No
In both ears
Right ear
Left ear
Noise in your ears?
*
Yes
No
In both ears
Right ear
Left ear
If yes, to noise in your ears, please explain.
Fullness in your ears?
*
Yes
No
In both ears
Right ear
Left ear
Pain in your ears?
*
Yes
No
In both ears
Right ear
Left ear
Discharge from your ears?
*
Yes
No
In both ears
Right ear
Left ear
Do you experience any of the following?
Double vision?
*
Yes
No
Constant
In episodes
Numbness in face or extremities?
*
Yes
No
Constant
In episodes
Blindness?
*
Yes
No
Constant
In episodes
Weakness in arms or legs?
*
Yes
No
Constant
In episodes
Confusion or loss of consciousness?
*
Yes
No
Difficulty with speech?
*
Yes
No
Difficulty with swallowing?
*
Yes
No
Head injury - check Y or N and if yes, please explain
Have you ever been knocked unconscious?
*
Yes
No
If you have been knocked unconscious, please explain.
Do you have or have you had any of the following (check all that apply)
Skull fracture
Neck injury
Eye problems
Neuropathy
Have you had numbness in your feet?
*
Yes
No
Have you had a stroke?
*
Yes
No
Have you had loss of vision?
*
Yes
No
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