Appendix 21-A: Initial Evaluation Form

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:

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

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

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

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

If yes, please describe __________

How often do you fall? __________

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:

If yes, please describe ____________________

When did it occur? ____________________

What medications do you take?

____________________

____________________

____________________