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? _________________________________________________________________________

ANDREW MARLOWE, MD, PA

Otolaryngology
Vertigo/Dizziness/Imbalance Questionnaire
8. 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. Is there anything about your dizziness that makes you think that it is coming from your ears?
What? _________________________________________________________________________
10. Do you have any blood relatives with dizziness or ear problems?
YES
NO
Who? _________________________________________________________________________
What problem? __________________________________________________________________
11. Did you ever injure your head?
YES
NO
Were you unconscious?
YES
NO
When was your injury? ___________________________________________________________
12. Have you been on any medications to help the dizziness?
YES
NO
Which? ________________________________________________________________________
Did they help?
YES
NO
13. Do you use tobacco in any form?

YES

NO

14. Do you have poor circulation?

YES

NO

15. Do you have diabetes?

YES

NO

16. Do you have trouble with vision?

YES

NO

17. Are your feet or toes numb?

YES

NO

9.

Do you have any of the following ear symptoms? Please circle yes or no and the ear involved.

1. Difficulty in hearing?
2. Stuffiness or pressure in ears?
3. Pain in ears?
4. Fluid from ears?
5. Noise in ears or head?**
6. 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, please ask for and fill out a Tinnitus Questionnaire.
10. Have you ever experienced any of the following symptoms?
1. Double, blurred or loss of vision?
2. Numbness of face, arms or legs?
3. Weakness in arms or legs?
4. Clumsiness in arms or legs?
5. Confusion or loss of consciousness?
6. Difficulty with speech?
7. Difficulty with swallowing?
8. 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