Russett Rehabilitation and Wellness Clinic Vestibular Intake
Date
/
Month
/
Day
Year
Date
Name
Age
Occupation
Describe the major problem or reason you are seeing us:
When did the problem begin?
Please select if you experience any of the following:
Vertigo (sense of spinning)
Dizziness
Tinnitus (ringing in the ears)
Nausea
Vomiting
Imbalance
Hearing loss
Pressure in the ears
Headaches
Double vision
Blurred vision
Is the vertigo/dizziness:
Yes
No
Constant
Spontaneous
Induced by motion
Induced by position changes
Is the feeling of being off-balance:
Yes
No
Constant
Spontaneous
Induced by motion
Induced by position changes
Worse with fatigue
Worse outside
Worse in the dark
Does the feeling of being off-balance occur when:
Yes
No
Lying down
Standing
Sitting
Walking
Do you or have you fallen (to the ground)?
Yes
No
How often do you fall?
Do you stumble, stagger or side-step while walking?
Yes
No
Do you drift to one side while you walk?
Yes
No
If yes, to which side do you drift?
Right
Left
Past Medical History: Do you have:
Yes
No
Diabetes
High Blood Pressure
Osteoarthritis
Back Problems
Hearing Problems
Heart Disease
Headaches
Neck Problems
Lung Problems
Visual Problems
Have you ever had surgery on your ears?
Yes
No
Have you been in an accident?
Yes
No
If YES, when did it occur?
Did you experience any head trauma?
Yes
No
Have you ever had a concussion?
Yes
No
How many?
What medications are you taking?
Do you live alone?
Yes
No
If, NO who lives with you?
Do you have stairs in your home?
Yes
No
Do you have trouble sleeping?
Yes
No
Are you independent in self-care activities?
Yes
No
Can you drive: In the daytime?
Yes
No
In the night time?
Yes
No
Are you working?
Yes
No
N/A
Are you Medical Disability?
Yes
No
Are you able to:
Yes
No
Watch TV comfortably?
Go shopping?
Read?
Be in traffic?
Be in a noisy place?
Work on computer?
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