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ANDREW MARLOWE, MD, PA

Otolaryngology
Vertigo/Dizziness/Imbalance Questionnaire
NAME: _______________________________________

DATE: _____________________

Please understand that the following questions are difficult to answer and vague. Dizziness is a very
difficult problem to diagnose and this form is an important part of your care.
A. When you are “dizzy” do you experience any of the following sensations? Please read the entire list, then check
yes or no to describe your feelings most accurately.
1. Lightheadedness or swimming sensation in the head

YES

NO

2. Near blacking out or loss of consciousness

YES

NO

3. Tendency to fall:
To the right?
To the left?

YES
YES

NO
NO

Forward?
Backward?

4. Objects spinning or turning around you

YES
YES

YES

NO
NO
NO

5. Sensation that you are spinning inside, with outside objects remaining stationary

YES

6. Loss of balance when walking

YES

NO

7. Headache

YES

NO

8. Nausea or vomiting

YES

NO

NO

B. Please try to answer all questions. Circle yes or no and fill in the blank spaces.
1.

2.

My dizziness is:
Constant?
In attacks?

YES
YES

NO
NO

When did dizziness first occur (very first episode ever)?

3. If in attacks: How Often? ______________________________________________________________
How long do they last? ___________________________________________________________
When was the last attack? _________________________________________________________
Do you have any warning that the attack is about to start?
YES
NO
Do they occur at any particular time of day or night?
YES
NO
Are you completely free of dizziness between attacks?
YES
NO
4. Does change of position make you dizzy?

YES

NO

5. Do you have trouble walking in the dark?

YES

NO

6. When you are dizzy, must you support yourself when standing?

YES

NO

7. Do you know of any possible cause of your dizziness?
YES
NO
What? _________________________________________________________________________

Difficulty with swallowing? 8. Weakness in arms or legs? 4.ANDREW MARLOWE. Do you have any of the following ear symptoms? Please circle yes or no and the ear involved. MD. Have you ever experienced any of the following symptoms? 1. Did you ever injure your head? YES NO Were you unconscious? YES NO When was your injury? ___________________________________________________________ 12. Stuffiness or pressure in ears? 3. Do you have trouble with vision? YES NO 17. Fluid from ears? 5. 10. Noise in ears or head?** 6. Is there anything about your dizziness that makes you think that it is coming from your ears? What? _________________________________________________________________________ 10. please ask for and fill out a Tinnitus Questionnaire. Clumsiness in arms or legs? 5. Do you have diabetes? YES NO 16. arms or legs? 3. Pain in neck or shoulder? NO NO NO NO NO NO NO NO YES YES YES YES YES YES YES YES CONSTANT CONSTANT CONSTANT CONSTANT CONSTANT CONSTANT CONSTANT CONSTANT EPISODES EPISODES EPISODES EPISODES EPISODES EPISODES EPISODES EPISODES . Do you have poor circulation? YES NO 15. Numbness of face. Difficulty with speech? 7. 1. Double. Do you use tobacco in any form? YES NO 14. Pain in ears? 4. Does the noise change with the dizziness? NO NO NO NO NO YES YES YES YES YES NO YES BOTH EARS BOTH EARS BOTH EARS BOTH EARS BOTH EARS RIGHT EAR RIGHT EAR RIGHT EAR RIGHT EAR RIGHT EAR LEFT EAR LEFT EAR LEFT EAR LEFT EAR LEFT EAR ** If you have noise in ears or head. Do you know of anything that will: (fatigue? Exertion? Hunger? Menstrual Period? Stress?) Stop your dizziness or make it better? Make your dizziness worse? Precipitate an attack? YES YES YES NO NO NO 9. Do you have any blood relatives with dizziness or ear problems? YES NO Who? _________________________________________________________________________ What problem? __________________________________________________________________ 11. blurred or loss of vision? 2. Difficulty in hearing? 2. PA Otolaryngology Vertigo/Dizziness/Imbalance Questionnaire 8. Have you been on any medications to help the dizziness? YES NO Which? ________________________________________________________________________ Did they help? YES NO 13. Confusion or loss of consciousness? 6. Are your feet or toes numb? YES NO 9.