NAME ___________________________________________ DATE________________________

I. What are the general characteristics of your dizziness? Please read the entire list first, then put an X in the first box for YES or the second box for NO and fill in the Blank Spaces.

__YES NO
1.)___ ___When did dizziness first occur? ________________________________
2.) ___ ___When my dizziness first started it began quickly.
3.)___ ___When my dizziness first started it began slowly.
4.) How long did the first spell last? _______________________________
5.) ___ ___My dizziness is: (Circle all that apply) Constant In Attacks
6.) If in attacks: How often ______________________________________
How long do they last? ____________________________ ? ? Do you have any warning that the attack is about to start?
7.)___ ___Are you completely free of dizziness between attacks?
8.)___ ___Does dizziness occur only in certain positions?
9.)___ ___Do you have trouble walking in the dark?
10.)___ ___When dizzy, must you support yourself when standing?
11.)___ ___Do you know any possible cause of your dizziness?
If YES, what? _________________________________________
12.) Do you know anything that will:
___ ___Stop your dizziness or make it better.
___ ___Make your dizziness worse?
___ ___Cause an attack?
13.)___ ___Were you exposed to any irritating fumes, paints, etc., at the onset of the dizziness?

II. When you are “dizzy” do you experience any of the following sensations? Please read the entire list first, then put an X in the first box for YES or the second box for NO and fill in the Blank Spaces.

__YES NO
1.)___ ___Lightheadedness
2.)___ ___Swimming sensation in the head
3.)___ ___Blacking out
4.)___ ___Loss of consciousness
5.)___ ___Tendency to fall (Circle all that apply)
To the Right To the Left Forward Backward
6.)___ ___Objects are spinning or turning around you
7.)___ ___Sensation that you are spinning or turning inside with outside objects remaining stationary
8.)___ ___Loss of balance when walking (Circle all that apply)
veering to the right veering to the left
9.)___ ___Headache
10.)___ ___Nausea or vomiting
11.)___ ___Pressure in the head
12.)___ ___Lightning-like flashes in your eyes

III. Do you have any of the following symptoms? Put an “X” in the appropriate box and circle which ear it involves.

__YES NO
1.)___ ___ Difficulty hearing (Circle all that apply) Both ears Right Ear Left Ear
When did this start_____________________________________
___ ___Is it getting worse?
2.) ___ ___Does your hearing change with your dizziness
If YES, how? __________________________________________
3.) ___ ___Noise in your ears? (Circle all that apply) Both ears Right Ear Left Ear
How long_________ Left ear__________ Right Ear __________
Describe the noise ____________________________________________
___ ___ Does the noise change with the dizziness?
If YES, how? ________________________________________________
___ ___ Does anything stop the noise or make it worse?
If YES, what? _______________________________________________
4.)___ ___Fullness/stuffiness in your ears Both ears Right Ear Left Ear
___ ___ Does this change when you are dizzy
5.) ___ ___Pain in your ears Both ears Right Ear Left Ear

6.)___ ___Discharge from you ears Both ears Right Ear Left Ear

7.)___ ___Do you get headaches associated with your dizziness
If YES, where do you feel the pain? ___________________________________
How long does the pain last? _________________________________________
What relieves your headaches? _______________________________________

IV. Have you ever experienced any of the following symptoms? Put an “X” in the appropriate box and circle if CONSTANT or in EPISODES.

__YES NO
1.)___ ___Double vision Constant Episodes
2.)___ ___Numbness of face or extremities Constant Episodes
3.)___ ___Blurred vision or blindness Constant Episodes
4.) ___ ___Weakness in arms or legs Constant Episodes
5.)___ ___Clumsiness in arms or legs Constant Episodes
6.)___ ___Confusion or loss of consciousness Constant Episodes
7.) ___ ___Difficulty with speech Constant Episodes
8.)___ ___Tingling around mouth Constant Episodes
9.)___ ___Spots before the eyes Constant Episodes
10) ___ ___ Headaches Constant Episodes
If YES, where do you feel the pain? ____________________________________
How long does the pain last? __________________________________________
What time of day do you get headaches? _________________________________
What relieves your headaches? ________________________________________

V. Please answer the following questions.

How many ounces of caffeinated drinks (coffee, tea or pop) do you drink daily? ________________

How much salt do you use? (circle one)

Add a lot Add a little None added Avoid all salty foods

VI. Please check the appropriate box for either YES or NO.

__YES NO
1.)___ ___Do you get dizzy after exertion or overwork
2.)___ ___Have you had any recent unusual straining/heavy lifting
3.)___ ___ Did you get new glasses recently
4.)___ ___Do you tend to get upset easily
5.)___ ___ Do you get dizzy when you have not eaten for a long time
6.)___ ___ Is your dizziness connected with your menstrual period
7.)___ ___Have you ever had a neck injury
8.) ___ ___ Have you ever been knocked out badly enough to have to go to the