This form is to be completed along with the adult hearing health history form. Please submit both forms prior to your appointment. To download a PDF of this form, please CLICK HERE! Personal Information Name * Date of Birth * Email * Have you ever experienced dizziness, lightheadedness, unsteadiness, or vertigo? * YesNo Are you feeling dizzy or unsteady today? * YesNo How often do you feel dizzy/unsteady? * Describe in your own words how your dizziness or unsteadiness feels * Is your dizziness/unsteadiness accompanied by * nausearinging or noises in your ear(s)hearing lossvisual disturbancesOther If other, explain Have you fallen in the last 12 months due to your dizziness/unsteadiness? * YesNo If yes, how many falls have you experienced in the last 12 months? If you have fallen, have you been injured? * YesNo If yes, please describe your injury Do you tend to fall to the * RightLeftBackFrontNo Pattern Do you currently take a Vitamin D supplement? * YesNo Do you experience visual difficulties or disturbances? * YesNo If yes, please describe When did your problem start? * Was there any related event? * YesNo If yes, describe Was the onset of your problem * GradualSuddenOther If other, describe If your dizziness is not constant, do you have any warning the attacks will occur? * YesNo If yes, describe If YES, do you have dizziness/unsteadiness between attacks? YesNo Does your dizziness/unsteadiness occur with position changes? * YesNo If yes, check all that apply Rolling your body right or leftTurning your head left or rightLooking up, or head back positionBending over, or head down positionGoing from lying to sitting positionOther If other, describe Do you know of anything that makes your dizziness/unsteadiness better? * YesNo If yes, check all that apply Not moving your headRestMedicationOther If medication, describe * If other, describe Do you know of anything that makes your dizziness/unsteadiness worse? * YesNo If yes, check all that apply Moving your headRiding or driving in the carLarge crowds or busy walkwaysWhen you’re hungry or haven’t eatenOther If other, describe Since it began, is your dizziness/unsteadiness currently * BetterWorseSame Do your symptoms limit your daily activities? * YesNo Do you have trouble walking in the dark or at dusk? * YesNo Do you have trouble walking on uneven surfaces (eg. lawn)? * YesNo When dizzy/unsteady, must you support yourself to stand or walk? * YesNo Do you have a history of migraine headaches? * YesNo Have you ever had IV antibiotics or chemotherapy? * YesNo Have you ever suffered a concussion (head injury)? * YesNo Do you have trouble sleeping? * YesNo Do you have pain, fullness, or pressure in your ears? * YesNo If yes, which ears Right earLeft earBoth ears If yes, does it coincide with your dizziness/unsteadiness? YesNo Have you experienced any of the following (Indicate if constant or episodic): 1. Double/blurred vision or blindness * YesNo If yes, is it ConstantEpisodic Comments 2. Numbness of face or extremities * YesNo If yes, is it ConstantEpisodic Comments 3. Weakness in arms or legs * YesNo If yes, is it ConstantEpisodic Comments 4. Clumsiness in arms or legs * YesNo If yes, is it ConstantEpisodic Comments 5. Confusion or loss of consciousness * YesNo If yes, is it ConstantEpisodic Comments 6. Difficulty with speech or swallowing * YesNo If yes, is it ConstantEpisodic Comments Have you seen other healthcare providers for this problem? YesNo If yes, who? Primary MDEar, Nose, Throat MD (ENT)NeurologistAudiologistCardiologistEmergency Room MDPhysical Therapist Have you had tests done for this problem elsewhere? ENG/VNG * YesNo Where When Results MRI/CT * YesNo Where When Results Hearing tests * YesNo Where When Results Other Signature * Date * Please arrive 15 minutes prior to your scheduled appointment time.