QUESTIONNAIRE 

for patients with

Fax to 312-274-0198 or bring in with you at your first appointment

A newer version can be found here

 

 

NAME:

BIRTH DATE:

TODAY'S DATE:

SOCIAL SEC #:

MED REC#:

HOME PHONE OR CELL PHONE:

WORK PHONE:

PHARMACY PHONE:

FAX #::

Email address:

SEND REPORT TO:

  

YOUR ADDRESS:

 

  

 

Do we have your permission to ask your doctor for records related to the reason for this appointment ?

 

 

YES

Signature

Date  

 

 

Please answer the following questions and bring the answers to your appointment. There is room at the end of each section for additional comments. Please give necessary details for "yes" answers. We realize that this form is long, but when it is filled out carefully it allows us to devote more time to examining you.

 

1. Present Illness I am here because of (circle all that apply)

  • Dizziness
  • Imbalance
  • Hearing Problem

    • Note: if you are seeing the doctor for a different reason, ask the receptionist for the proper questionnaire.

    My symptoms started on:

     

    Circle the specific symptoms that you have.

    Others (describe):

      

    Are the main symptoms constantly present, or do they appear in attacks ?

     

     

    If in attacks,

    Associations

    2. Are your dizziness, vertigo or imbalance, or hearing problems affected or brought on by:

     

    Changes in position of the head or body

    (for example, turning over in bed)

    Standing up

    Rapid head movements

    Walking in a dark room

    Elevators

    Airplane, boat or car travel

    Loud noises

    Coughing, blowing the nose, sneeze, or straining

    Grocery stores, narrow or wide open spaces

    Exercise

    Foods, eating or not eating, salt,

    monosodium glutamate (MSG)

    Heat, hot showers

    Time of day, particular seasons

    Stress

    Alcohol

    Menstrual periods (if relevant)

    Underwater Diving

     

     

    Other Triggers ?:

     

    3. Ear Problems:

    Have you ever had (circle side)

    4. Life Style

     

    5. Injuries (circle)

     

    6. Exposures (circle)

    8. Past or present health has been affected by (circle)

     Constitutional

     CARDIOVASCULAR

    CANCER

    What type ?

    ENDOCRINE

    PSYCHOLOGICAL

    PAIN

     IMMUNOLOGIC

    BREATHING PROBLEM

     STOMACH PROBLEM

    EYE PROBLEM

    NEUROLOGICAL PROBLEM

    RENAL/GENITOURINARY

    SURGERY

     

     

    FAMILY HISTORY 

    9. Are there any family members with (circle, list):

     

    MEDICATIONS

     

    10a. What are your current medications, include hormones, allergy shots, birth control pills, vitamins, etc. (Name and amount/day)?

     

     

     

    10b. What other medications have you taken in the last 3 years, for this problem or others ?

     

     

    10c. Have you ever taken any of the following drugs ?

    Circle the ones that you have taken.

    PREVIOUS STUDIES

     11. Have you had any of these tests ? (circle, date) (please note if abnormal)

      

    THANK YOU !

     

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