Vestibular Screening Questionnaire
Name
*
First Name
Last Name
Date
*
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Month
-
Day
Year
Date
Cardiovascular Status and Comorbidities
1) Do you have any of the following conditions:
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Older than 65 y/o Diabetes
High Cholesterol
Light Headed/Fainting
Nausea
Multiple Sclerosis
A-Fib/Arrythmia
History of Stroke
Smoker
Blurred Vision
Numbness of mouth
Carotid Artery Stenosis
Worst Headache EVER
Myasthenia Gravis
Difficulty Swallowing
Falls in last 3 months
Congenital Nystagmus
Parkinson’s
Cancer
Difficulty Finding Words
Depression
2) Do you currently have an infection or have recently gotten over an infection? If so, how long ago?
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Vestibule and Cochlea Status
3) Are you experiencing any of the following symptoms:
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Nausea/Vomiting
Tendency to Fall to a Particular Side Pain
Pressure in Ear
Ringing in Ear
Spinning Sensation When Still
Hearing Loss
I am experiencing none of these symptoms
4) When did your symptoms start to come on? Has it been persisting longer than a week?
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5) Do your symptoms come on spontaneously without warning, with bright lights/sounds/ odors/bearing down, or with movement? If with movement, what kind?
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6) How long does an episode of your symptoms last for? Less than one minute or greater than one minute?
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7) Have you had multiple episodes or just one episode?
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Status of Cerebellum
8) Have you recently had trauma to the back of the head?
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9) Do you have history of posterior head injury?
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10) Do you have history of stroke to posterior area of the brain?
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11) Do you have a chronic alcohol use problem?
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Other Questions
12) Have you had any imaging or hearing tests done? What were the results?
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