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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):

  • _____less than two minutes;

  • _____20 – 30 minutes;

  • _____2 – 4 hours;

  • _____12 – 24 hours;

  • _____1 – 3 days;

  • _____always present;

  • _____other (please write in duration)

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.

  1. 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

  2. Sense of movement of the environment or of one's own body

    • ( ) Rotation (spinning, tumbling or cartwheeling);

    • ( ) Tilt

  3. Sensations not associated with movement of the environment

    • ( ) Lightheadedness or impending faint;

    • ( ) Floating;

    • ( ) Swimming;

    • ( ) Rocking;

    • ( ) Fear or avoidance of being in public places

  4. Associated symptoms

    • ( ) Sweating;

    • ( ) Nausea;

    • ( ) Vomiting;

    • ( ) Queasiness

  5. Impaired vision

    • ( ) Double vision;

    • ( ) Blurred vision;

    • ( ) Jumping of vision when walk or ride in a car

2. To what extent is your dizziness or imbalance brought on by:

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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

3. Other questions concerning dizziness...

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