Date:_____________

Name:_________________________________________ DOB:____________

1. When did your dizziness begin?___________________________________________

2. Currently, my dizziness…..(Check all that apply)
[ ] Is Constant
[ ] Is constant but waxes and wanes
[ ] Comes and goes

3. On average, how often does dizziness occur?
More than once per day____
Once every_____ hours/days/weeks/months
(circle one)

4. On average, how long does each dizzy spell last?
[ ] Seconds
[ ] Minutes
[ ] Hours

5. My dizziness mostly consists of (check all that apply):
[ ] Spells of spinning with nausea
[ ] Off-balance sensation
[ ] Light-headed or near-faint sensation
[ ] Other. Please explain:__________________________________________

6. Between episodes, I feel: (Check only one)
[ ] Dizzy or off-balance all the time
[ ] Normal
[ ] Other. Please explain:__________________________________________

7. Dizziness usually occurs:
[ ] When I turn my head to quickly or in certain directions
[ ] Spontaneously; nothing specific brings them on
Describe any particular head motion (or other movement) that causes dizziness: ________________________________________________________________________

8. When I roll over in bed (check one):
[ ] The room seems to spin every time
[ ] The room seems to spin sometimes
[ ] Nothing usually happens

9. Have you noticed any hearing loss?
[ ] No
[ ] Yes. Please describe:__________________________________________