DIZZINESS IMBALANCE HEARING PROBLEMS
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- Jasper Bryan
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1 DIZZINESS IMBALANCE HEARING PROBLEMS Chicago Dizziness and Hearing 645 N. Michigan, Suite 410 Chicago, Illinois, NAME AGE TODAY'S DATE SOCIAL SEC # HOME PHONE WORK PHONE PHARMACY YOUR FAX Sex: M F Birthdate: / / SEND REPORT TO: YOUR ADDRESS: Single Married Widowed Separated Divorced Patient Employed by: Business Address:Street City State Zip Primary Insurance: Secondary Insurance: Card Holder Name: Card Holder Name: Sign below to indicate that: 1. We offered you a copy of our Privacy Policy statement for your review 2. We have your permission to ask your doctor for records related to the reason for this appointment 3. I hereby authorize the release of any information needed by my carrier to process the claim. I understand that I am financially responsible for all charges; these may include, but are not limited to, deductibles, co-pays, and non-covered services. 4. We have your permission to use video material of your eye (where you cannot be recognized) in research or educational works. Signature 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.
2 1. Present Illness I am here because of (circle all that apply) Dizziness (such as vertigo) Imbalance Hearing Problem (hearing loss, tinnitus, fullness) Note: if you are mainly seeing the doctor for a different reason, such as headache or another neurological problem, ask the receptionist for the headache or neurological questionnaire. My symptoms started on: Circle the specific symptoms that you have. Spinning, tumbling, cart-wheeling, tilting or rocking Nausea, vomiting Double, blurred or jumping vision Light-headedness Headache If Yes, Do bright lights bother you? Y N Loud noises? Y N Strong Smells? Y N Motion? Y N Ear symptoms (such as tinnitus, fullness, hearing loss, pain) Others (describe): 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?
3 Associations and Triggers 2. Are your dizziness, vertigo or imbalance, or hearing problems affected or brought on by TRIGGER YES NO Changes in position of the head or body (for example, turning over in bed) Standing up Rapid head movements Walking in a dark room Elevators Airplane, boat or car travel Loud noises Coughing, blowing the nose, or straining Grocery stores, narrow or wide open spaces Exercise Foods, eating or not eating, salt, monosodium glutamate (MSG) Heat, hot showers Time of day, particular seasons Stress Alcohol Menstrual periods (if relevant) Underwater Diving Are there other triggers?: 3. Ear Problems: Have you ever had (circle side) Abnormal Sounds in ear No Right Left If Yes, is it Ringing? Hissing? Buzzing? Locust? Musical? Voices? Crickets? Sensitivity to Noise No Right Left Fullness or pressure in ear No Right Left Pain in ear No Right Left Unable to hear clearly No right Left Do you use a hearing aid? No Right Left
4 4. Life Style How much do you smoke per day? Diet: How much salt do you use on your food? How much alcohol do you drink per week? Do you commonly eat chocolate? Y N Do you eat much food with MSG? Y N Do you eat much aged cheese? Y N What sort of work do you do (or used to do)? How often do you fly on airplanes? Are you presently in litigation or planning litigation about symptoms related to this visit? Are you disabled due to your condition? (Women of childbearing age only) are you pregnant? Y N Perimenopausal? Y N How many pillows do you use to sleep at night? In what position do you mainly sleep at night? (circle) Back Stomach Right-down Left-down Any 5. Injuries (circle, date if significant) to ears to head (for example, concussion) 6. Exposure (circle) Loud noise (industrial)
5 7. Past or present health has been affected by (circle) Constitutional Weight Loss (15 LB or more) Trouble sleeping? Due to dizziness? Due to depression? Due to snoring? Due to sleep apnea? CARDIOVASCULAR Anemia Fainting Heart problems High cholesterol High blood pressure Low blood pressure Diabetes Palpitations (abnormal or fast beating) of the heart CANCER What type and when? ENDOCRINE Low sugar (hypoglycemia) Thyroid disorder PSYCHOLOGICAL Treatment by a psychiatrist or counselor Depression Unusual amounts of stress PAIN Arthritis Pain in back of jaw (TMJ) Migraine, Sinus or tension headaches Low Back Pain Neck Pain IMMUNOLOGIC Allergy (to what?) Lupus/other autoimmune disease BREATHING PROBLEMS Asthma Pneumonia Sinusitis Deviated Septum STOMACH PROBLEMS Ulcer Reflux/Hiatal Hernia Irritable bowel EYE PROBLEMS (other than glasses) Crossed eyes, lazy eye Poor vision in one eye Cataract Macular Degeneration Double vision? NEUROLOGICAL PROBLEMS B12 Deficiency Carpal Tunnel Memory loss Meningitis Multiple Sclerosis Pins and needles, numbness (where) Muscle, paralysis or weakness (where) Seizures Speech disturbance Tremor or incoordination RENAL/GENITOURINARY Bladder Problem Sexual function problem Kidney problem
6 8. SURGERY OTONEUROLOGY QUESTIONNAIRE Appendix Breast Cataract Carotid C-Section Ear Epidural Injection Gall Bladder Hysterectomy Prostate Sinus Stomach Tonsils Other FAMILY HISTORY 9. Are there any family members with (circle, list): Dizziness, balance or hearing symptoms: Balance problems Hearing loss starting at age < 40 Otosclerosis Vertigo or dizziness Meniere's syndrome Symptoms like your own Convulsions or seizures Migraine headaches Other diseases that run in the family? (please list) What is your ancestry? (some ancestries, such as French Canadian, are a little more prone to develop dizziness) 6
7 MEDICATIONS OTONEUROLOGY QUESTIONNAIRE 10a. What are your current medications, include hormones, allergy shots, birth control pills, CPAP. (Name and amount/day)? b. What other medications have you taken in the last 5 years, for this problem? c. Have you undergone physical therapy for your condition? Chiropractic treatment? Acupuncture? Alternative medicines (such as Ginkgo, St. Johns Wort?) 10d. Have you ever taken any of the following drugs? Mark the ones that you have taken. Aspirin, in large dosage Cisplatin (for cancer) Furosemide (Lasix) Gentamicin (antibiotic) Larium or other drugs for malaria prevention Streptomycin (obsolete antibiotic) Tamoxifen (to prevent breast cancer) Tobramycin (antibiotic) Vancomycin (antibiotic) 7
8 PREVIOUS STUDIES OTONEUROLOGY QUESTIONNAIRE 11. Have you had any of these tests? (date if done and note result if known) EAR TESTS: BAER test (evoked potential test) ECOG (evoked potentials for Meniere's syndrome) ENG Caloric test (hot and cold, water or air in ear), Hearing test (audiogram) OAE (Otoacoustic emissions) Posturography test (balance test) Rotatory Chair test (spinning test) VEMP (vestibular evoked myogenic potential) NEUROLOGICAL TESTS Carotid Doppler or cerebral angiogram EEG (Brain wave test for seizures) Lumbar puncture (spinal fluid examination, spinal tap) GENERAL MEDICAL TESTS X-RAYS Recent general medical checkup? Recent general blood tests blood count, Cholesterol Glucose, Thyroid tests Heart testing (EKG, Echo, Stress test, Holter Monitor) Tilt table test Chest X-ray Ear: CT scan of inner ear (Temporal bone CT) Head: MRI, MRA and/or CT scan Neck: X-rays, CT or MRI scan PET scan Sinus: X-rays or CT scan Other Important Tests: 8
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Your child has been referred to the Health4Life Program at Children's Healthcare of Atlanta. We are located at the Scottish Rite Campus in the Medical Office Building. In order to serve you and your child