15 W. Dry Creek Circle                                                                                           6169 S. Balsam Way; Suite 290
         Littleton, CO  80120-4427                                                                                                                                   Littleton, Colorado  80123
     Phone: (303)  798-1309                                                                                                                                        Fax: (303) 798-2319
Ear, Nose & Throat Center
Specialists of the Ear, Nose and Throat   /  Head and Neck Surgery  /  Facial Plastic Surgery
Evaluation  of  Dizziness  &  Vestibular Disorders

For more information see us at our web site !      http://www.ENT Center.Net
   


VERTIGO QUESTIONNAIRE

This Questionnaire should be filled out by the patient at home and brought to the office so the
doctor can review it during the office visit.  Please print a copy to bring with you.

1. How long have you been dizzy ?  ______________________________________________________
2. Is the dizziness continual or intermittent ? _______________________________________________
3. Does the dizziness make you nauseated or vomit? _________________________________________
4. When do you become dizzy ? _________________________________________________________
5. What makes you dizzy ? _____________________________________________________________
   _________________________________________________________________________________
6. Do you become dizzy when you suddenly sit or stand up ? __________________________________
7. Do you become dizzy when turning over in bed or when looking upward? ______________________
8. Is your dizziness more like spinning, whirling, or is it more like lightheadedness ?________________
9.  Have you ever blacked out, lost consciousness or fainted with dizziness? ______________________
10. Do you have a hearing loss ? ________________________________________________________
11. Which ear ? ______________________________________________________________________
12. How long have you had a hearing loss? ________________________________________________
13. Is your hearing getting worse ? _______________________________________________________
14. Does your hearing loss fluctuate or change or is it a steady hearing loss ? ______________________
I5. Do you have ringing in your ears? _____________________________________________________
16. Which ear? _______________________________________________________________________
17. How long ? ______________________________________________________________________
18. Do you have pressure or fullness in your ears ? __________________________________________
19. Which ear ? ______________________________________________________________________
20. How long ? ______________________________________________________________________
21. Have you ever had any previous ear operations ? _________________________________________
22. What kind of surgery was performed ? _________________________________________________
23. For what reason ? _________________________________________________________________
24. When was the operation done? _______________________________________________________
25. Have you ever had any ear injuries ? ___________________________________________________
26. Have you ever had chronic ear or mastoid infection ? _____________________________________
27. Have you ever had a skull fracture, concussion, or significant head injury ?_____________________
28. Have you ever had any neurological diseases ?___________________________________________
       Stroke ? _______ epilepsy or seizures ?_______ migraine headaches ?_______________________
29.  Have you ever had any undiagnosed chronic illness ? _____________________________________
      ________________________________________________________________________________

30.  List all medications. _______________________________________________________________
        Name of drugs ? _________________________________________________________________
        Dosage or strength (frequency that you take the drug) ? __________________________________
        Length of time that you have been taking this medication ? ________________________________
31.   Is the dizziness associated with double vision, or blurred vision ? ____________________________
32.  Does the dizziness occur with headaches? _____________________________________________
33.  Does it occur with numbness of the lips, fingertips, or sensation of shortness of breath,   anxiousness or nervousness, or   
        tightness or pressure in your chest? _____________________________________________________
34. Have you ever been treated for hyperventilation syndrome ? ________________________________
35. Have you ever been treated for chronic nervousness, chronic depression or anxiety ? _________________________________________________________________________________
36. Have you ever had high blood pressure, cardiac disease, disturbance in the rhythm or rate of the heart beat ? ___________________________________________________________________________
37. Have you ever had a heart attack or angina ? ____________________________________________
38. Do you have any history of diabetes, hypoglycemia, elevation of the cholesterol or blood lipids (fat levels) ? __________________________________________________________________________
39. Do you have any history of thyroid diseases or history of any endocrine (glandular diseases) ? _________________________________________________________________________________
40. Has any other physician ever treated you for dizziness ? ____________________________________
41. When, the diagnosis, recommendations ? ________________________________________________
42. Have you ever had any arthritis of the neck, injury to the neck, or any whiplash injury ? ________________________________________________________________________________________________________________________________________________________________________________________________