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Evaluation

Initial: Yes No

Follow-up: Yes No

Date: __________

Patient: __________ Medical Record #: __________

D.O.B. __________ Age: __________

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

Describe the major problem or reason you are seeing us:

When did this problem begin? __________________

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

If yes, how long do these spells last? __________

When was the last time the vertigo occurred? __________

Is the vertigo:

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

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

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

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

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

If yes, please describe __________

How often do you fall? __________

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Have you injured yourself? Yes No

If yes, please describe: __________

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

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

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

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

Pertinent Past Medical History

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

If yes, please describe ____________________

When did it occur? ____________________

What medications do you take?

____________________

____________________

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