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Vestibular Questionnaire
Magnolia Physical Therapy & Wellness, Inc
Full Name :
*
First Name
Last Name
Birth Date :
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If you are not a Magnolia patient, please provide phone number :
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Dizziness Questions
Check all answers that apply
1. In the last four weeks I have experienced:
Double, blurred or jumping vision
Light-headedness
Falls
Dizziness (room spinning)
Imbalance
Hearing problems (hearing loss, tinnitus,fullness).
2. I experience headaches:
Yes
No
Not at present, but have experienced migraines or cluster headaches in the past
3. My symptoms began:
4. The following me in the last four weeks:
Bright lights
Loud sounds
Strong odors
Motion (rolling / turning head)
Moving from sit to stand
Ear symptoms
Other
5. My dizziness, vertigo, imbalance, or hearing problems get worse with:
Changes in positioning of my head
Rolling over in bed
Rapid head turns
Walking in a dark room
Elevators
Airplane, boat, or car travel
Loud noises
Coughing, blowing my nose, or straining
Grocery stores or narrow spaces
Wide spaes
Foods (eating salt, MSG, chocolate for example)
Heat or hot showers
Time of day or seasons of the year
Stress
Alcohol
Menstrual periods
Underwater diving
Other
6. I have experienced ear problems:
none
hissing
buzzing
locust
musical
voices
cricket
sensitivity to noise
fullness or pressure in the ear
pain in the ear
Other
7. I wear hearing aids:
No
Yes, right side
Yes, left side
Yes, both sides
9. I mainly sleep on:
My back
My stomach
My right side
My left side
Any
Other
10. I have had an injury to my ear/s
yes
no
11. Immediate members of my family have had or have
Dizziness
Balance problems
Vertigo or dizziness
Hearing loss
Meniere's
Symptoms like my own
Seizures
Migraines
Other
12. If you have had any of the following exams please list date and findings:
i.e. BAER test, MRI, EEG, etc
Is there anything else you would like us to know ?
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