Dizziness Questionnaire

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Dizziness Questionnaire 1/5
Please submit this questionnaire prior to your appointment
- I accept the above
Right-click this text and select Save link as... to download this questionnaire as a PDF. Please make sure to open in Adobe Acrobat Reader
Patient’s Details:
Name:*
Address:*
DOB:*
Phone/Mobile:*
Gender:*
- Female
- Male
The following questions refer to your feeling of dizziness. Please fill in all the blanks.
Have you in the past, had an off balance/vertigo/dizzy symptom sensation?*
- Yes
- No
If so, please describe in your own words the off balance/vertigo/dizzy symptom sensation you experienced THEN without using the word “dizzy”. If there are more than one distinct type of sensation please describe both:
Please describe if any significant events which led up to THE VERY FIRST initial off balance/vertigo/dizzy symptom sensation ever experienced, even if was years ago (eg cold or flu symptoms, flight, head trauma):
Do you currrently have an off balance/vertigo/dizzy symptom sensation?*
- Yes
- No
If so, Please describe in your own words the off balance/vertigo/dizzy symptom sensation you CURRENTLY feel without using the word “dizzy”. If there are more than one distinct type of sensation please describe both:
Also, please describe if any significant events which led up to the CURRENT off balance/vertigo/dizzy symptom sensation you feel (eg cold or flu symptoms, flight, head trauma):
Please describe how long the symptoms lasted for and if symptoms changed:
Do you ever have any of the following sensations?*
- Spinning in circles
- Falling to one side
- World spinning around you
- None of the above

Dizziness Questionnaire 2/5
Please submit this questionnaire prior to your appointment
- I accept the above
The following questions refer to typical dizzy spells. Select only those that apply and answer as appropriate.
Do your dizzy spells come in attacks?*
- Yes
- No
How often?
How long do/did the attacks last for? Seconds/minutes/hours/days/weeks/months/constant: If more than one type of dizziness describe both:
Date of first spell/attack?
Are you currently feeling dizzy?*
- Yes
- No
Are you free from dizziness between attacks?*
- Yes
- No
Are you dizzy or unsteady constantly?*
- Yes
- No
Do you get any warning the dizziness is about to start?*
- Yes
- No
What are the warning signs?
Are you dizzy at certain times of the day or night?*
- Yes
- No
If so which?
Did you take any medications (inc strong antibiotics, chemotherapy, quinine etc) prior to symptom onset?*
- Yes
- No
If yes what were they?
Did you have any cold or flu like symptoms prior to onset?*
- Yes
- No
Does your hearing change with an attack?*
- Yes
- No
Do you only get dizzy when you move?*
- Yes
- No
Are you dizzy mainly when you sit or stand up quickly?*
- Yes
- No
Are you dizzy when you look up, down or bend forward or backwards?*
- Yes
- No
If so which?
Are you dizzy if you roll over in bed?*
- Yes
- No
If so in the right or left side?
Are you dizzier in certain positions?*
- Yes
- No
Which position?
Are you nauseated during an attack?*
- Yes
- No
Are you dizzy even when lying down?*
- Yes
- No
Does closing your eyes make your dizziness worse?*
- Yes
- No
Are you better if you sit or lie perfectly still?*
- Yes
- No
Have you had a recent cold or flu preceding recent dizzy spells?*
- Yes
- No
Have you had fullness, pressure, or ringing in your ears?*
- Yes
- No
Have you had pain or discharge in your ear of recent onset?*
- Yes
- No
Do you have a loss of balance when walking in dark?*
- Yes
- No
If so veering to the right or left?
Do you have a loss of balance when walking in the light?*
- Yes
- No
If so veering to the right or left?
Do loud sounds make you dizzy?*
- Yes
- No
Do you get dizzy when you cough, sneeze, blow nose, bowel movement or other?*
- Yes
- No
If so which?
Are your symptoms exacerbated or initiated when in upright posture eg. standing or sitting?*
- Yes
- No
If yes, please explain
Are your symptoms exacerbated or initiated when in motion eg. walking, driving, flying etc?*
- Yes
- No
If yes, please explain
Are your symptoms exacerbated or initiated when not in motion but visual stimuli gives impression of moving (eg. sitting in car and cars beside you move giving sensation of movement)?*
- Yes
- No
If yes, please explain
Are your symptoms exacerbated or initiated with seeing moving objects or complex visual patterns (eg. computer/TV screens with moving images, patterned carpets, clothes or pictures)?*
- Yes
- No
If yes, please explain
Any other comments about your dizziness you feel is pertinent?

Dizziness Questionnaire 3/5
Please submit this questionnaire prior to your appointment
- I accept the above
The following refer to other sensations you may have. Select only those that apply and answer as appropriate.
Do you black out or faint when dizzy?*
- Yes
- No
Have you had:*
- Select All
- Severe or recurrent headaches or migraines?
- Light and/or sound sensitivity leading up to or during your headaches or dizziness/vertigo?
- Visual Auras (eg. lines, spots, squiggles) leading up to or during your headaches or dizziness/vertigo?
- Any double or blurry vision?
- None of the above
Numbness in your face, ears or extremities?*
- Yes
- No
If yes, both sides, left or right?
Have you had:*
- Select All
- Weakness or clumsiness in arms, legs?
- Pain in the neck or shoulders?
- Slurred or difficult speech?
- Difficulty swallowing?
- Tingling around your mouth?
- Spots before your eyes?
- Jerking of arms or legs?
- Seizures?
- Confusion or memory loss?
- None of the above
Have you had any recent head trauma?*
- Yes
- No
If yes, please explain.
Have you had any other sensation variables you feel are pertinent to your condition?*
- Yes
- No
If yes, please explain.
The following refers to your hearing. Select only those that apply and indicate which side has been affected:
Difficulty hearing in one ear?
- Left
- Right
- Both
- None
Ringing or buzzing in one ear?
- Left
- Right
- Both
- None
Fullness in one ear?
- Left
- Right
- Both
- None
Change in hearing and tinnitus volume when dizzy?*
- Yes
- No
Does your hearing fluctuate?*
- Yes
- No
Can you hear your heartbeat, eyes blinking, or any other internal sounds?*
- Yes
- No
If so, which sound and which ears?
Own voice excessively loud?*
- Left
- Right
- Both
- None
Have you had any other variables to do with your hearing you feel are pertinent?*
- Yes
- No
If yes, please explain.
Have you had any of the following?
Pain in ears?*
- Left
- Right
- Both
- None
Discharge from ears?*
- Left
- Right
- Both
- None
Hearing change for the better?*
- Left
- Right
- Both
- None
Hearing change for the worse?*
- Left
- Right
- Both
- None
Exposure to loud noises?*
- Yes
- No
Previous ear infections?*
- Yes
- No
Trauma to your ear(s)?*
- Yes
- No
Previous ear surgery?*
- Yes
- No
If yes, what kind?
Family history of deafness?*
- Yes
- No

Dizziness Questionnaire 4/5
Please submit this questionnaire prior to your appointment
- I accept the above
The following refer to habits and lifestyle. Select only those that apply and answer as appropriate.
Is there added stress to your life recently?*
- Yes
- No
Is your dizziness related to:*
- Select All
- Moments of stress?
- Menstrual period?
- Overwork or exertion?
- Hunger?
- Emotional upset?
- Changes in weather/atmospheric pressure?
- Do you feel light-headed or have a swimming sensation when you are dizzy?
- Do you find yourself breathing faster or deeper when excited or dizzy?
- Did you recently change eyeglasses?
- Have you ever had weakness or faintness a few hours after eating?
- None of the above
Is your dizziness related to any of the following?
Do you drink coffee?*
- Yes
- No
How much and how often?
Do you drink tea?*
- Yes
- No
How much and how often?
Do you drink soft drinks?*
- Yes
- No
How much and how often?
Do you drink alcohol?*
- Yes
- No
How much and how often?
Do you smoke?*
- Yes
- No
What?
How much and how often?
Describe any other variables you feel may contribute to your dizziness:
Past medical history:
Please list your current medical problems and length of illness:*
Please list all surgery performed and approximate dates:*
Please list all allergies (including drugs) and reaction:*
Please list all medicines you currently take for your dizziness that HAVE provided some relief or benefit with your symptoms:*
Please list all medicines you currently take for your dizziness that HAVE NOT provided some relief or benefit for you:*
Please list all medicines you currently take (including pain medicine, nonprescription medicine, nerve pills, sleeping pills, or birth control pills).*
Have you had any previous testing eg hearing, x-rays, head scans, etc?*

Dizziness Questionnaire 5/5 - Please submit this questionnaire prior to your appointment
Family history:
Any family history of any of the following? Select all that apply.*
- Select All
- Migraine?
- Off Balance/Vertigo/Dizziness or tinnitus?
- High blood pressure?
- Low blood pressure?
- Diabetes?
- Low blood sugar?
- Thyroid disease?
- Asthma?
- Multiple Sclerosis?
Please list any other diseases that run in your immediate family:
Any other comments you feel are pertinent to your condition:
Declaration:
I confirm that for my appointment I will:*
- Select All
- Not wear make-up
- Not eat anything for 8 hours prior
- Have no caffeine for 12 hours prior
- Have no alcohol for 48 hours prior
- Have no nicotine (cigarettes, gum, patches etc) for 12 hours prior
- Not take - tranquilisers, sedatives, vestibular suppressants (eg Stemetil, Serc) and painkillers for 24 hours prior
All information on this form is true and accurate and I consent to the use of any data/results both on this form and from the audio-vestibular testing to be used anonymously for research purposes*
- Yes
- No
We require all patients to follow the above guidelines for BOTH assessments. If these guidelines are not followed your appointment will be rescheduled to another date.
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Dizziness Questionnaire

Step 1 of 5

Dizziness Questionnaire 1/5

Patient’s Details:

The following questions refer to your feeling of dizziness. Please fill in all the blanks.

Dizziness Questionnaire 2/5

The following questions refer to typical dizzy spells. Select only those that apply and answer as appropriate.

Dizziness Questionnaire 3/5

The following refer to other sensations you may have. Select only those that apply and answer as appropriate.

The following refers to your hearing. Select only those that apply and indicate which side has been affected:

Have you had any of the following?

Dizziness Questionnaire 4/5

The following refer to habits and lifestyle. Select only those that apply and answer as appropriate.

Is your dizziness related to any of the following?

Past medical history:

Dizziness Questionnaire 5/5 - Please submit this questionnaire prior to your appointment

Family history:

Declaration:

We require all patients to follow the above guidelines for BOTH assessments. If these guidelines are not followed your appointment will be rescheduled to another date.

Quick Links

Get in touch