14575 Southfield Rd.
Allen Park, Mi. 48101
Ph. 313-381-8787
Fax 313-381-8790
22255 Greenfield #200
Southfield, Mi. 48075
Ph. 248-304-7772
Fax 248-918-2038
BALANCE QUESTIONNAIRE
Name:________________________________
Date:_______
Patients: In order to fully evaluate your complaints, please complete all questions
and bring this survey with you when your return for your balance function testing.
1. Describesymptoms/complaintsindetail:
2. Whendidsymptomsbegin:
3. Howlongdosymptomslast(Circleanswer):
secondsminuteshoursdays
4. Howoftendosymptomsoccur(Howmanytimespertime): constantdailyweeklymonthlyyearly
5. Symptomsoccurwhen:
walkingstandingsittinglayinganytime
Doyouhave:
Imbalance/unsteadiness
Historyoffalling Spinning/tumbling
Rocking/swaying
Lightheadedness Fainting/BlackingOut Nausea/vomiting
DoubleVision
JumpingVision (whilewalking/riding)
Aresymptomsworsenedby:
Lyingdownorrollingover
Sittingorstandingup Walkingindarkness
Walkingonunevensurfaces
Hotbaths/showers
MenstrualCycle Exercise Reading/ComputerWork
LoudNoises
Coughing,Sneezing,Straining
Headturnswhilewalking
No
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Yes
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Spells
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Ears/Eyes: No Right
HearingLoss
___ ____ FluctuatingHearing
___ ____ Tinnitus(ringing,buzzing,etc.) ___ ____ FrequentEarinfections ___ ____ Perforated/TornEardrum
___ ____ EarSurgery
___ ____ EarInjuries
___ ____ EyeInjury ___ ____ EyeSurgery
___ ____ UseofEyePatch ___ ____ HeadacheHistory Headaches:No
Yes
Howoftendotheyoccur:
daily
weekly
monthly
Howlongdotheylast? minutes hours
days
HeadachemedicationsList:________________________________
Migraine: Yes No
SincehowLong?________________
Withnauseavomiting yes No
Causedbycertainfood/drink Yes No
Familyhistoryofmigraine
Yes No
Relatedtomenstrualcycle
Yes No Habits:
Alcohol:__________________________
Caffeine:__________________________
Tobacco:___________________________
RecreationsDrugs:___________________
N/A
Left
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PastMedicalHistory:Pleasedescribeandlistdates.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
MotorVehicleAccident:
HeadInjury:
Chronicillness(e.g.diabetes,hypertension)requiringmedication:
Intravenousantibiotics,chemotherapy,radiationtherapy:
Medications:Pleaselist
Please follow instructions carefully before coming for your Balance tests. Failure to
do so will result in wrong diagnosis. Ensure that you have an accompanying driver
to take you back home after the tests.
Lascelles Pinnock, MD
Websites:
www.downriverentpc.com
Rajashree Natarajan, AUD CCC-A
www.platinumhearingaids.com