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Dizziness Questionnaire
Please fill out the form as completely as possible. The more information provided will help us understand your condition.
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Email
*
Your email
Name
Your answer
City where you currently are living
Your answer
What is your age?
Your answer
In what month and year did your symptoms FIRST begin?
Your answer
During what activities do your symptoms occur?
Your answer
What makes your symptoms better?
Your answer
What makes your symptoms worse?
Your answer
Have your symptoms changed recently? If so, how?
Your answer
Have you received a diagnosis related to your dizziness? If so, what is it?
Your answer
Have you received treatment for your symptoms? If so, please describe.
Your answer
Name of ENT or neurologist (if applicable)
Your answer
Describe your symptoms
Your answer
Do you have symptoms when you roll over in bed?
Yes
No
Sometimes
Clear selection
List your medications
Your answer
Do you smoke, or vape, tobacco products?
Yes
No
I have in the past, not currently
Clear selection
Have you had any new hearing loss?
Yes
No
Clear selection
Do you experience headaches or migraines? If so, please describe
Your answer
In what position do you primarily sleep? Check all that apply
On back
On stomach
On right side
On left side
Other:
List your past medical history and any surgeries you have had
Your answer
What do you hope to achieve with treatment?
Your answer
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