for patients with
Fax to 312-274-0198 or bring in with you at your first appointment
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SOCIAL SEC #:
HOME PHONE OR CELL PHONE:
SEND REPORT TO:
Do we have your permission to ask your doctor for records related to the reason for this appointment ?
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.
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.
Are the main symptoms constantly present, or do they appear in attacks ?
If in attacks,
how often ?
how long ?
Do you have any warning that an attack is about to start ?
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)
Rapid head movements
Walking in a dark room
Airplane, boat or car travel
Coughing, blowing the nose, sneeze, or straining
Grocery stores, narrow or wide open spaces
Foods, eating or not eating, salt,
monosodium glutamate (MSG)
Heat, hot showers
Time of day, particular seasons
Menstrual periods (if relevant)
Other Triggers ?:
3. Ear Problems:
Have you ever had (circle side)
Abnormal Noise in ear Right Left
If Yes, is it Ringing ? Hissing ? Musical ?
Sensitivity to Noise Right Left
Fullness or pressure in ear Right Left
Unable to hear clearly Right Left
Pain in ear Right Left
4. Life Style
How much alcohol do you drink ?
How much do you smoke ?
How much salt do you use on your food ?
What sort of work do you do (or used to do) ?
How often do you fly on airplanes ?
Are you involved with litigation regarding your medical problems ?
5. Injuries (circle)
head (for example whiplash)
6. Exposures (circle)
8. Past or present health has been affected by (circle)
Weight Loss (15 LB or more)
High or low blood pressure
Palpitations (abnormal or fast beating) of the heart
What type ?
Low sugar (hypoglycemia)
Treatment by a psychiatrist or counselor
Unusual amounts of stress
Pain in back of jaw (TMJ)
Migraine, Sinus or tension headaches
Low Back Pain
Allergy (to what ?)
Mononucleosis (Epstein Barr)
Crossed eyes, lazy eye
Poor vision in one eye
Pins and needles, numbness (where)
Muscle, paralysis or weakness (where)
Tremor or incoordination
Sexual function problem
Gall Bladder Surgery
9. Are there any family members with (circle, list):
Dizziness, balance or hearing symptoms:
Hearing loss starting at age < 40
Vertigo or dizziness
Other symptoms like your own
Convulsions or seizures
Other diseases that run in the family? (list)
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.
Aspirin, in large dosage
Malaria drugs (quinine)
11. Have you had any of these tests ? (circle, date) (please note if abnormal)
BAER (evoked potentials for acoustic neuroma)
ENG Caloric test (water in ear)
ECOG (evoked potentials for Meniere's syndrome)
Hearing test (Audiogram)
Posturography test (balance test machine)
Rotatory Chair test (spinning test)
Lumbar puncture (spinal fluid examination)
EEG (Brain Wave test for seizures)
Recent general medical checkup?
Recent general blood tests
MRI and/or CT scan of the head
Angiogram of the head
THANK YOU !
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