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Home
About
About Us
Our Staff
Service Area
Our Services
Redcord
DRY NEEDLING
WELLNESS AND RECOVERY
More
Gallery
Contact Us
faq
Blog
Back Pain
Patient Forms
Menu
Home
About
About Us
Our Staff
Service Area
Our Services
Redcord
DRY NEEDLING
WELLNESS AND RECOVERY
More
Gallery
Contact Us
faq
Blog
Back Pain
Patient Forms
Call Us Now
Vestibular Questionnaire
Vestibular Questionnaire
First Name
Last Name
Birth Date
If you are not a Magnolia patient, please provide phone number
Area Code
Phone Number
Dizziness Questions
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
5. My dizziness, vertigo, imbalance, or hearing problems get worse with
Changes in positioning of my hea
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
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
7. I wear hearing aids
No
Yes, right side
Yes, left side
Yes, both sides
8. I mainly sleep on
My back
My stomach
My right side
My left side
Any
9. I have had an injury to my ear/s
Yes
No
10. 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
11. If you have had any of the following exams please list date and findings:
Is there anything else you would like us to know ?
Submit
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