Dizziness Questionnaire

Name……..……………..Date of birth…………

Tel No…………………...Today’s Date…………

 

1.Describe your symptom as accurately as you can.

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2. When exactly did it start?

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3.Is it there all the time?

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4.Does anything bring it on or make it worse?

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5.Does anything make it easier?

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6.Are your sight or hearing affected?

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7.Do you lose consciousness or faint?

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8.Please list any tablets or treatments you are taking, including those not actually prescribed by a doctor.

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9.Are you more depressed or worried than usual?

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10.Is there anything in your lifestyle which could be contributing to the problem?

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11. Do you know of anyone who has a similar problem?

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12. Could you express any opinions or secret fears that may have crossed your mind or been suggested as to the cause of the pain.

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13.please describe any other symptoms.

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14. Is there anything else I should know?

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Examination

Temperature…….…BP………….Pulse………..

Neck movements………………………………..

Ear Drums……….Rinnee………………Weber…….

Fundi………….

Neurological Examination

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Diagnosis and Plans: