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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? YES NO Forward? YES NO

To the left? YES NO Backward? YES NO

4. Objects spinning or turning around you YES NO

5. Sensation that you are spinning inside, with outside objects remaining stationary YES NO

6. Loss of balance when walking YES NO

7. Headache YES NO

8. Nausea or vomiting YES NO

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

1. My dizziness is:

Constant? YES NOIn attacks? YES NO

2. 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? _________________________________________________________________________

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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? YES NO

Make your dizziness worse? YES NO

Precipitate an attack? YES 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? NO YES BOTH EARS RIGHT EAR LEFT EAR

2. Stuffiness or pressure in ears? NO YES BOTH EARS RIGHT EAR LEFT EAR

3. Pain in ears? NO YES BOTH EARS RIGHT EAR LEFT EAR

4. Fluid from ears? NO YES BOTH EARS RIGHT EAR LEFT EAR

5. Noise in ears or head?** NO YES BOTH EARS RIGHT EAR LEFT EAR

6. Does the noise change with the

dizziness? NO YES

** 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? NO YES CONSTANT EPISODES2. Numbness of face, arms or legs? NO YES CONSTANT EPISODES

3. Weakness in arms or legs? NO YES CONSTANT EPISODES

4. Clumsiness in arms or legs? NO YES CONSTANT EPISODES

5. Confusion or loss of consciousness? NO YES CONSTANT EPISODES

6. Difficulty with speech? NO YES CONSTANT EPISODES

7. Difficulty with swallowing? NO YES CONSTANT EPISODES8. Pain in neck or shoulder? NO YES CONSTANT EPISODES