Describe your major problem or the reason why you are seeing us.
Please describe in detail the circumstances and date in which the problem began and what were your initial symptoms and problems. Was there any stress or anxiety around the onset of the problem?
If you have spells, please describe a typical spell in as much detail as possible and describe the frequency and duration of the spells.
Duration (please check which most closely fits what you experience):
What do you personally think your problem is due to?
1. Please check the symptoms which characterize your problem and grade their severity from 2 (marked), 1 (moderate) to 0 (none). Put 0 if you do not have these symptoms.
Sensation of imbalance
( ) Trouble with walking. Do you use a cane, walker or wheel chair, touch walls or furniture, or use a person for balance inside buildings (If yes, please circle all that apply).
( ) Poor balance.
( ) Falls. How many falls have you had in the past 6 months, in which you unexpectedly lost your balance and landed on the floor or ground _______? Please circle all that apply: indoors, outdoors, poor lighting, due to fatigue, while turning, while standing up or sitting down.
Check ( ) if the fall(s) were due to your dizziness
Sense of movement of the environment or of one's own body
Sensations not associated with movement of the environment
( ) Sweating;
( ) Nausea;
( ) Vomiting;
( ) Queasiness
2. To what extent is your dizziness or imbalance brought on by:
|Check one answer for each question. ||None ||Some ||Severely |
|Getting out of bed on the right side______left side____ || || || |
|Turning over in bed, bending over or looking up || || || |
|Standing up || || || |
|Rapid head movements || || || |
|Walking in a dark room || || || |
|Walking on uneven surfaces || || || |
|Loud noises || || || |
|Cough, sneeze, strain, laugh, blowing up balloons || || || |
|Movement of objects in the environment || || || |
|Moving your eyes while your head is still || || || |
|Wide open spaces || || || |
|Tunnels, bridges, supermarkets || || || |
|Menstrual periods || || || |