аЯрЁБс>ўџ @Bўџџџ?џџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџьЅС)` №Пњ0bjbj€€ 44т{т{yџџџџџџЄЄЄЄЄЄЄЄИ\\\\ hИsЖž      $)h‘|ФiЄФЄЄ-jjj ЄЄžjžjjЄЄj„ `*~УpCг\šnjžC0sj X j Єj4jФФ` sИИИЄ \ИИИ\ИИИЄЄЄЄЄЄџџџџ DIZZINESS QUESTIONNAIRE NAME: DOB: DATE: I When you are "dizzy" do you experience any of the following sensations? Please read the entire list first. Then check yes or no to describe your feelings most accurately. Yes Ё% No Ё% 1. Lightheadedness or swimming sensation in the head. Yes Ё% No Ё% 2. Blacking out or loss of consciousness. Yes Ё% No Ё% 3. Tendency to fall: To the right? Yes Ё% No Ё% To the left? Yes Ё% No Ё% Forward? Yes Ё% No Ё% Backward? Yes Ё% No Ё% 4. Objects spinning or turning around you. Yes Ё% No Ё% 5. Sensation that you are turning or spinning inside, with outside objects remaining stationary. Yes Ё% No Ё% 6. Sensation of the environment moving up and down while you walk. Yes Ё% No Ё% 7. Loss of balance when walking: Veering to the right? Yes Ё% No Ё% Veering to the left? Yes Ё% No Ё% 8. Headache. Yes Ё% No Ё% 9. Nausea or vomiting. Yes Ё% No Ё% 10. Pressure in the head. Yes Ё% No Ё% 11. Palpitations, perspiration, shortness of breath, or a feeling of panic. II Please check yes or no and fill in the blank spaces. Answer all questions. 1. My dizziness is: Yes Ё% No Ё% Constant? Yes Ё% No Ё% In attacks? 2. When did dizziness first occur? 3. If in attacks: How often? How long do they last? When was the last attack? Yes Ё% No Ё% Do you have any warning that the attack is about to start? Yes Ё% No Ё% Do they occur at any particular time of day or night? Yes Ё% No Ё% Are you completely free of dizziness between attacks? Yes Ё% No Ё% 4. Does change of position make you dizzy? Yes Ё% No Ё% 5. Do you have trouble walking in the dark? Yes Ё% No Ё% 6. When you are dizzy, must you support yourself when standing? Yes Ё% No Ё% 7. Do you know of any possible cause of your dizziness? 8. Do you know of anything that will: Yes Ё% No Ё% Stop your dizziness or make it better? Yes Ё% No Ё% Make your dizziness worse? Yes Ё% No Ё% Precipitate an attack? (Fatigue? Exertion? Hunger? Menstrual Period? Stress? Emotional? Upset?) Yes Ё% No Ё% 9. Were you exposed to any irritating fumes, paints, etc., at the onset of dizziness? Yes Ё% No Ё% 10. If you are allergic to any medications, please list: .68:>HRZbltV X и к > Ц Ш ŒИšЈъњ6@„ŽШЮV`&v†арф"XЮжитіј"2#8#B#V#Т#Ш#к#т#((8(Є(А(К(Ю(ъ()f)ј0њ0їђїюъюхюхюхюънъюйюйдйдйдйдйдйъйдйдйдйдйъйаЫдаЫаЩаЫаЫаЫаЫаЫаЫаЫаъаХО hH7hXhXU hH7>*hH7 hИ>*hИh>hih…tБ>* h…tБ>*h>hih…tБ hИ5hИhИ5C02468:<>vxzV и ^ Ь , f ˜ Ь < ( Ш Pžвh§§§§§§§§§§§§§§§§§§§§§§§§§§§§§њ0ўИшLЈњB.КFЖ(ТФЦЪЬ`Д†т~DијŒ"8#X#§§§§§§§§§§§§§§§§§§§§§§§§§§§§§ Yes Ё% No Ё% 11. If you ever injured your head, were you unconscious? Yes Ё% No Ё% 12. If you take any medication regularly, for any reason, please list: Yes Ё% No Ё% 13. Do you use tobacco in any form, how? How much? III Do you have any of the following symptoms: Please check yes or no and check ear involved. Yes Ё% No Ё% 1. Difficult in hearing? Both ears Ё% Right Ё% Left Ё% Yes Ё% No Ё% 2. Noise in your ears? Both ears Ё% Right Ё% Left Ё% 2a. How loud is your tinnitus or head noise most of the time? Ё% None No head noise. Ё% Very Soft Heard only in a quiet situation. Ё% Moderate Heard only in an ordinary situation. Ё% Loud Heard and noticed in all situations, even when concentrating on something else. 2b. Describe the noise. 2c. Does noise change with dizziness? If so, how? Yes Ё% No Ё% 3. Fullness or stuffiness in our ears? Both Ё% Right Ё% Left Ё% Yes Ё% No Ё% 4. Pain in your ear? Both Ё% Right Ё% Left Ё% Yes Ё% No Ё% 5. Discharge from your ears? Both Ё% Right Ё% Left Ё% IV Have you ever experienced any of the following symptoms? Please check yes or no and check constant or in episodes. Yes Ё% No Ё% 1. Double vision, blurred vision or blindness. Constant Ё% In Episodes Ё% Yes Ё% No Ё% 2. Numbness of face. Constant Ё% In Episodes Ё% Yes Ё% No Ё% 3. Numbness of arms of legs. Constant Ё% In Episodes Ё% Yes Ё% No Ё% 4. Weakness in arms or legs. Constant Ё% In Episodes Ё% Yes Ё% No Ё% 5. Clumsiness of arms or legs. Constant Ё% In Episodes Ё% Yes Ё% No Ё% 6. Confusion of loss of consciousness. Constant Ё% In Episodes Ё% Yes Ё% No Ё% 7. 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