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Evaluation

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Initial: Yes No

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Follow-up: Yes No

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Date: __________

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Patient: __________ Medical Record #: __________

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D.O.B. __________ Age: __________

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Referring physicians and physicians to whom we should send report (please give addresses):

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Describe the major problem or reason you are seeing us:

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When did this problem begin? __________________

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Specifically, do you experience spells of vertigo (a sense of spinning)? Yes No

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If yes, how long do these spells last? __________

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When was the last time the vertigo occurred? __________

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Is the vertigo:

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spontaneous: Yes No
induced by motion: Yes No
induced by position changes: Yes No

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Do you experience a sense of being off-balance (disequilibrium)? Yes No

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If yes, is the feeling of being off-balance:

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constant: Yes No
spontaneous: Yes No
induced by motion: Yes No
induced by position changes: Yes No
worse with fatigue: Yes No
worse in the dark: Yes No
worse outside: Yes No
worse on uneven surfaces: Yes No

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Does the feeling of being off-balance occur when you are:

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lying down Yes No
sitting Yes No
standing Yes No
walking Yes No

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Do you or have you fallen (to the ground)? Yes No

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If yes, please describe __________

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How often do you fall? __________

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Have you injured yourself? Yes No

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If yes, please describe: __________

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Do you or have you had “near falls”? Yes No

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Do you stumble, stagger, or side-step while walking? Yes No

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Do you drift to one side while you walk? Yes No

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If yes, to which side do you drift? Right Left

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Pertinent Past Medical History

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Do you have:

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Diabetes:

Yes

No

Heart disease:

Yes

No

Hypertension:

Yes

No

Headaches:

Yes

No

Arthritis:

Yes

No

Migraines

Yes

No

Neck problems:

Yes

No

Back problems:

Yes

No

Pulmonary problems:

Yes

No

Weakness or paralysis:

Yes

No

Hearing problems:

Yes

No

If yes, describe ____________________
Visual problems: Yes No
If yes, describe ____________________
Have you been in an accident? Yes No

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If yes, please describe ____________________

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When did it occur? ____________________

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What medications do you take?

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____________________

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____________________

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