NAME_______________________________________________ DATE__________________

I. General characteristics of your dizziness (please circle)
1. Do you have any warning that the attack is about to start? Yes / No
2. Are you completely free of dizziness between attacks? Yes / No
3. Do you have trouble walking in the dark? Yes /No
4. When you are dizzy, do you have to support yourself when standing? Yes/ No
5. Do you know any possible cause of your dizziness? Yes/No
If yes, what is the cause? __________________________
6. Do you know anything that will stop your dizziness or make it better? Yes/No If yes, what? ________________________________________________
7. Do you know anything that will start your dizziness or make it worse? Yes/No
If yes, what? _________________________________________
8. Is your dizziness worse when you turn over in bed? Yes / No
9. Do you get dizzy after exertion or overwork? Yes / No
10. Do you get dizzy when you have not eaten on your regular schedule? Yes / No

II. Other sensations that occur with your dizziness
1. Lightheadedness Yes / No
2. Swimming sensation in the head Yes / No
3. Blacking out Yes / No
4. Loss of consciousness Yes / No
5. Tendency to fall Yes / No
To the right? Yes / No
To the left? Yes/ No
Forward? Yes / No
Backward? Yes / No
6. A feeling that objects are spinning or turning around you Yes / No
7. A feeling that you are spinning or turning but objects around
you are staying still Yes / No
8. Loss of balance when walking Yes/ No
9. Headache Yes / No
10. Nausea or vomiting Yes/No
11. Sensitivity to light Yes / No
12. Sensitivity to noise Yes/ No
13. Pressure or fullness in your ear(s) Yes/ No
14. Change in your hearing Yes / No
15. Change in ringing in the ears Yes / No
16. Flashes in your eyes like lightning Yes/ No

III. Do you have any of these other ear troubles? Please circle yes or no as well as which ear is involved.

1. Difficulty hearing Yes/No
Which ear? Both / Right / Left
When did this begin? ________________
Is it getting worse? Yes / No
2. Noise in your ears Yes/ No
Which ear? Both / Right / Left
Does it change with your heartbeat? Yes/ No
3. Pain in your ears Yes/ No
Which ear? Both / Right /Left

4. Drainage from your ears Yes /No
Which ear? Both / Right/ Left

IV. Please answer these final questions about situations that sometimes go along with dizziness

1. Double vision Yes / No
2. Numbness of face or arms or legs Yes/ No
3. Blurred vision or blindness Yes/ No

4. Weakness or clumsiness of your arms or legs Yes / No
5. Confusion Yes/ No
6. Difficulty with speech Yes/ No
7. Difficulty with swallowing Yes/ No
8. Tingling around mouth Yes/ No
9. Spots in front of your eyes Yes / No
10. Have you ever been knocked out badly enough to
have to go to the hospital? Yes / No
12. Have you ever had a neck injury? Yes / No
13. Headaches Yes / No
How long do your headaches last? Less than an hour
1-6 hours
______Hours
______Days
Constant
What relieves your headaches? Aspirin or Tylenol
Prescription pain medicine
Sleep
14. Have you had any recent unusually heavy lifting or straining? Yes /No
15. Did you get new glasses recently? Yes / No
16. Do you tend to get upset easily? Yes/ No
17. How many ounces of caffeinated drinks (coffee, tea, pop)
do you drink each day? Zero / _____ounces
18. How much salt do you use? Add a lot / Add a little / None added / A