Balance and Dizziness Questionnaire

First Name*

Cellphone

Surname*

Telephone

Email*

Which of the following symptoms do you experience?*

Spinning in circlesFalling to one sideWorld spinning around me

Please complete the following:

My dizzy spells come in attacks:YesNo

I am dizzier in certain positions? YesNo

I am free from dizziness between attacks: YesNo

My hearing changes with an attack: YesNo

I am dizzy if I stand up quickly: YesNo

I am nauseated during an attack: YesNo

I have had a recent cold or flu: YesNo

I have had fullness, pressure, or ringing in my ears: YesNo

I have had pain or discharge in my ears: YesNo

I have trouble walking in the dark: YesNo

I am better if I sit or lie perfectly still: YesNo

Loud sounds make me dizzy: YesNo

I black out or faint when dizzy: YesNo

I have severe or recurrent headaches: YesNo

I am sensitive to light during my headaches and/or dizziness: YesNo

I have double or blurry vision: YesNo

I have numbness in my face or extremities: YesNo

I have weakness or clumsiness in my arms/legs: YesNo

I have slurred or difficult speech: YesNo

I have difficulty swallowing: YesNo

I have tingling around my mouth: YesNo

I see spots before my eyes: YesNo

I have jerking of my arms/legs: YesNo

I have seizures: YesNo

I have confusion or memory loss: YesNo

I have had recent head trauma: YesNo

YesNo

I have difficulty hearing in one ear

LeftRightBoth

YesNo

I have ringing in one ear

LeftRightBoth

YesNo

I have fullness in one ear

LeftRightBoth

YesNo

I have a change in hearing when dizzy

LeftRightBoth

YesNo

Pain in ears

LeftRightBoth

YesNo

Discharge in ears

LeftRightBoth

YesNo

Hearing change

          Better

LeftRightBoth

          Worse

LeftRightBoth

YesNo

Exposure to loud noise

LeftRightBoth

YesNo

Ear infections

LeftRightBoth

YesNo

Trauma to ears

LeftRightBoth

YesNo

Previous ear surgery

LeftRightBoth

YesNo

I have a family history of deafness

LeftRightBoth

YesNo

There is added stress to my life recently

YesNo

I am dizzy or unsteady constantly

Is your dizziness related to:

YesNo

          Moments of stress?

YesNo

          Menstrual period?

YesNo

          Overwork or exertion?

YesNo

I feel lightheaded or “swimming” sensation when I am dizzy

YesNo

I breathe faster or deeper when excited or dizzy

YesNo

I recently changed eyeglasses

YesNo

I feel weak or faint a few hours after eating

YesNo

I drink coffee

YesNo

I drink tea

YesNo

I drink soft drinks

YesNo

I drink alcohol

YesNo

I smoke

YesNo

Migraine

YesNo

High blood pressure

YesNo

Low blood pressure

YesNo

Diabetes

YesNo

Low blood sugar

YesNo

Thyroid disease

YesNo

Asthma

Constitutional:
Weight
Fever
Fatigue

Eyes:
Eyes
Pain
Discharge/tearing

Skin:
Rash
Jaundice
Recent Baldness

Psychiatric:
Insomnia
Depression
On Meds? YesNo

Ear, Nose, Mouth, Throat:
Itchy ears
Nasal obstruction
Drooling
Nosebleed
Sneezing
Stuffy nose

 
Mouth growth, ulcer
Chewing difficulty
Lump in neck
Pain on swallowing
Heartburn
Sore throat

 
Nasal discharge
Facial weakness
Snoring
Dental problems
Voice changes

 
Loss of sense of smell
Growth in nose
Bleeding from throat
Breathing difficulty

Cardiovascular:
Chest pain
Irregular heart beat
Swelling of legs
Leg pain with walking
Leg pain with rest

Respiratory:
Wheezing
Cough
Shortness of breath
Mucous
Coughing up blood

Neurological:
Headache
Tremour
Blackout
Seizures
Paralysis

Endocrine:
Thyroid trouble
Heat/Cold intolerance
Excessive sweating
Excessive thirst, hunger, urination

Gastrointestinal:
Decrease in appetite
Diarrhoea/Constipation
Nausea/Vomiting
Indigestion
Blood in stool
Food intolerance

Genitourinary:
Painful urination
Difficulty passing urine
Venereal disease
Incontinence
Blood in urine
Frequent urination at night

Hematologic/Lymphatic:
Bleeding problems
Anaemia
Easy bruising
Blood disorder (such as Sickle Cell)

Musculoskeletal:
Neck pain
Joint pain/Stiffness
Arthritis