Dizziness Investigation Form Ding Xiuyong, Department of Otolaryngology-Head and Neck Surgery, Xuanwu Hospital, Capital Medical University
(Based on Practical Manual of Dizziness Diagnosis and Treatment, by JOEL A. GOBEL, translated by HAN ZHAO and WANG Z. (slightly modified)
Name: Gender: Age.
Do you have any of the following feelings when you have dizziness? Please read the whole book and tick the first column “Yes” or the second column “No” to describe your feelings.
Yes
No
Yes
No
1. Feeling like you are spinning or rotating, while your surroundings are still
Yes
No
2. Visual confusion or jumping when the head is in motion
Yes
No
3. When eyes are open, surrounding objects rotate or turn around oneself
Yes
No
4. When the glasses are closed, the surrounding objects rotate or turn around oneself
Yes
No
5. Losing balance when walking: turning to the left?
Yes
No
Turn to the right?
Yes
No
6, tendency to fall: to the right?
Yes
No
To the left?
Yes
No
Forward?
Yes
No
Backward?
Yes
No
7, The sensation of rotation or turning occurs when: lying down?
Yes
No
Turning to the left?
Yes
No
Roll over to the right?
Yes
No
Looking up, looking down, bending over?
Yes
No
8. Feeling of floating in the mind
Yes
No
9.Sense of rotation in the mind
Yes
No
10, light-headedness
Yes
No
11, unbalanced and unstable
Yes
No
12, Transient fainting/weakness
Yes
No
13, Loss of consciousness
Yes
No
14, Headache or head pressure sensation
Yes
No
15, Nausea and vomiting
II. Check “yes” or “no” and check the box, fill in the blank according to the actual situation
Yes
No
1, My dizziness is: persistent
Yes
No
Episodic
Yes
No
2. When was the first episode of dizziness?
Yes
No
3, If episodic.
How often do the episodes occur
How long does it last (only the time you feel yourself or your surroundings turning)
What were the signs or what were you doing before the seizure
Yes
No
4. Any dizziness between episodes?
Yes
No
5. Does dizziness occur only in specific locations?
Yes
No
6. Is it difficult to walk in the dark?
Yes
No
7. Do you have to hold on to something to stand when you are dizzy?
Yes
No
8. Do you know the possible causes of your dizziness?
What is it?
Yes
No
9, What would: stop the dizziness or make it better?
Make dizziness worse?
Cause an attack?
Yes
No
10. Do you have to face any irritating smell, paint, etc. when dizziness attacks?
What was it?
Yes
No
11, Do you have any allergies?
Yes
No
12, Have you ever had a head injury?
Yes
No
If yes, when?
Yes
No
Is there any loss of consciousness, if any?
Yes
No
13. Do you take any medications regularly?
What kind of medication?
Yes
No
14, Smoking or other tobacco use? How much?
Yes
No
15, Do you drink alcohol? On average, how much per day? ml
Yes
No
16, how many cups of coffee, tea or cola per day do you routinely quote?
Yes
No
17. Have you ever had ear surgery? When? What kind of surgery?
III. Do you have any of the following symptoms? Tick the first column “Yes” or the second column “No” and place a check mark in front of the affected ear.
Yes
No
1,Hearing problem? □ both ears □ right ear □ left ear
Yes
No
When did it occur?
Yes
No
Is it getting worse?
Yes
No
Do your hearing levels fluctuate?
Yes
No
Do you wear hearing aids?
Yes
No
2. Do you have tinnitus?
Yes
No
Try to describe the tinnitus
Yes
No
Does the tinnitus change when you are dizzy? If so, how does it change?
Yes
No
3. Do you have a feeling of fullness or numbness in your ears? □both ears □right ear □left ear
Yes
No
Any change in dizziness?
Yes
No
4. Do you have ear pain? □both ears □right ear □left ear
Yes
No
5. Do you have ear leakage? □both ears □right ear □left ear
Yes
No
6. Is there any distortion in hearing? □both ears □right ear □left ear
Yes
No
7. Are you sensitive to sound? □binaural □right ear □left ear
Yes
No
8. Do you feel any ear overflow? □both ears □right ear □left ear
IV. Do you have the following symptoms? Tick “Yes” in the first column or “No” in the second column, and check the duration.
Yes
No
1, double vision □ persistent □ intermittent
Yes
No
2, light spots in front of the eyes □ persistent □ intermittent
Yes
No
3, blurred vision □ persistent □ intermittent
Yes
No
4, Numbness of the face or extremities □ persistent □ intermittent
Yes
No
5, visual confusion or blackness □ persistent □ intermittent
Yes
No
6, Weakness or clumsiness in arms or legs □ Persistent □ Intermittent
Yes
No
7, Speech difficulty □ Persistent □ Intermittent
Yes
No
8, difficulty swallowing □ persistent □ intermittent
Yes
No
9, perioral tingling □ persistent □ intermittent
Yes
No
10, confusion or jumping of visual objects during head movement □ persistent □ intermittent
V. Tick “Yes” in the first column or “No” in the second column
Yes
No
1. Do you experience dizziness after exertion or overwork?
Yes
No
2. Have you recently gotten new glasses?
Yes
No
3. Do you get upset easily?
Yes
No
4. Do you feel dizzy after not eating for a long time?
Yes
No
5. Is there any connection between dizziness and menstruation or fluid retention?
Yes
No
6. Have you ever had a neck injury?
Yes
No
7, Do you have diabetes? Insulin Oral medication
Yes
No
8, Do you have high blood pressure? Usual blood pressure mmHg oral medication
Yes
No
9, Do you have heart disease? Medication
Yes
No
10, Do you have high blood fat? Medication