yes	no	Do you experience dizziness? When did it last occur?
		Does it occur constantly in attacks?
		How often are your attacks? (per week? month?) When was your first attack? How long do they last? What symptoms if any precede and attack?
yes	no	Are you always somewhat dizzy, even between attacks?
yes	no	Does changing positions make you dizzy? Explain.
yes	no	Do you have trouble walking in the dark?
yes	no	Can you stand up unsupported when you are dizzy?
		What do you think might be causing your dizziness?
		What, if anything will stop your dizziness or make it better?
		What, if anything will bring on a dizziness attack?
		Do any of the following make you dizzy?
yes	no	walking in a supermarket
yes	no	going up in a fast elevator
yes	no	lifting heavy objects
		Please explain any relationship you may have noticed between eating and your dizziness.
		Please list any fumes paints etc. that you were exposed to at the onset of your dizziness.
		Please explain any accidents (motor vehicle equipment etc.) that you have ever been involved in.
		Please explain any head injuries you may have suffered. Were you unconscious as a result? yes no
		Please list any surgeries you have undergone. Were there any complications? yes no
		When you are dizzy, do you experience any of the following sensations?
yes	no	Light Headedness
yes	no	Swimming sensation in head
yes	no	Blacking out
yes	no	Loss of Consciousness
yes	no	Tendency to fall right left forward backward
yes	no	Objects spinning or turning around you
yes	no	Sensation that you are turning or spinning inside, when outside objects remain stationary.
yes	no	Loss of balance when walking veering to the left veering to the right
yes	no	Headache
yes	no	Vomiting
yes	no	Pressure in the head
yes	no	Other (explain)

yes	no	Double vision	constant	in attacks
yes	no	Blurred Vision	constant	in attacks
yes	no	Blindness	constant	in attacks
yes	no	Hallucinations (seeing objects that aren't there)	constant	in attacks
yes	no	Numbness of face	constant	in attacks
yes	no	Numbness around your mouth	constant	in attacks
yes	no	Numbness of your arms and legs	constant	in attacks
yes	no	Weakness in your arms or legs	constant	in attacks
yes	no	Clumsiness in your arms and legs	constant	in attacks
yes	no	Loss of consciousness	constant	in attacks
yes	no	Difficulty with speech	constant	in attacks
yes	no	Difficulty swallowing	constant	in attacks

yes	no	Difficulty Hearing	right	left
	For how long have you had a hearing loss in your left ear? Right ear?
yes	no	Is this hearing loss constant?	right	left
yes	no	Do you have noise in the ears?	right	left
	For how long have you had noise in your left ear?   Right ear?
yes	no	Is this noise constant?	right	left
	Describe the Noise.
yes	no	Does the noise change with dizziness? How?
yes	no	Does the volume of the noise change in a noisy place?	better	worse
yes	no	Does the volume of the noise change in a quiet place?	better	worse
yes	no	Does the volume of the noise change in daytime?	better	worse
yes	no	Does the volume of the noise change at night?	better	worse
yes	no	Do you have fullness, stuffiness or pressure in your ears?	right	left
	How long have you had pressure in your right ear? left ear?
yes	no	Does this pressure change with dizziness? How?
		Pain in your ears? right left both
		Is the pain constant intermittent?
		Discharge from your ears? right left both
		Right ear discharge first occurred how long ago?
yes	no	Do you have a right ear discharge now? If so, for how long?
		Left ear discharge first occurred how long ago?
		Do you have a left ear discharge now? If so, for how long?
yes	no	Have you ever been exposed to loud noises? If so, for how long? For how many years? Did you have ear protection? yes no
yes	no	Has anyone in your family had a hearing problem? Who? What type of hearing loss?

 

yes	no	Do you have allergies? To what?
yes	no	Do you take medication regularly? What medication and how often?
yes	no	Do you drink alcohol? When was the last time you had a drink?
yes	no	Do you use tobacco in any form?
yes	no	Are you under any unusual strain or tension?
yes	no	Do you experience pain or clicking in your jaw? Does it change with eating?
yes	no	Do you have any problems with your vision? Explain
yes	no	Do you have any orthopedic problems (bone / joint) Explain
yes	no	Do you have arthritis problems? Explain
yes	no	Do you have any problems walking? Explain
yes	no	Have you ever had syphilis?
yes	no	Have you ever had Yaws?
yes	no	Have you ever had Pinto?
yes	no	Have you ever had high blood pressure?
yes	no	Have you ever had a stroke?
yes	no	Have you ever had Multiple Sclerosis?
yes	no	Have you ever had a lack of blood to the brain?
yes	no	Have you ever had a brain tumor?
yes	no	Have you ever had diabetes?
yes	no	Have you ever had ear infections?
yes	no	Have you ever had mastoid infections?
yes	no	Have you ever had a Migraine?
yes	no	Have you ever had Thyroid gland problems?
yes	no	Have you ever had Anemia?
yes	no	Have you ever had Cancer?
yes	no	Has anyone in your family had hearing problems dizziness or vertigo?

Please indicate any other information regarding your symptoms, which you feel is not mentioned in the above questions.