Dizziness Questionnaire
Name .. ..Date of birth
Tel No ...Todays Date
1.Describe your symptom as accurately as you can.
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2. When exactly did it start?
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3.Is it there all the time?
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4.Does anything bring it on or make it worse?
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5.Does anything make it easier?
6.Are your sight or hearing affected?
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7.Do you lose consciousness or faint?
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8.Please list any tablets or treatments you are taking, including those not actually prescribed by a doctor.
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9.Are you more depressed or worried than usual?
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10.Is there anything in your lifestyle which could be contributing to the problem?
11. Do you know of anyone who has a similar problem?
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12. Could you express any opinions or secret fears that may have crossed your mind or been suggested as to the cause of the pain.
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13.please describe any other symptoms.
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14. Is there anything else I should know?
Examination
Temperature . BP .Pulse ..
Neck movements ..
Ear Drums .Rinnee Weber .
Fundi .
Neurological Examination
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Diagnosis and Plans: