lvphysio_Vestibular

Name

Date

Age

Occupation

Referring Physician

Describe the major problem or reason you are seeing us:

When did the problem(s) begin:

Have you been in an accident?

YesNo

If yes, when did it occur?

If yes, please briefly describe the accident

What medications are you taking?

Have you ever experienced a sustained (> 2 minutes) period of spinning vertigo?

YesNo

Have you experienced shorter spells of spinning vertigo?

YesNo

If YES, how long do these spells last?

When was the last time the vertigo occurred?

Does the vertigo occur:

Rows	Yes	No
Spontaneously with no head movement?
Induced by head positional changes?
Induced by rolling onto your side?

RightLeft

you experience a sense of being off-balance (disequilibrium or dizziness)?

YesNo

If YES, is the feeling of being off-balance:

Rows	Yes	No
constant all the time
occurring spontaneously (no movement)
induced by motion
induced by position changes
worse with fatigue
worse outside
worse in the dark
worse when on uneven surfaces

Does the feeling of being off-balance occur when:

Rows	Yes	No
lying down
sitting
standing
walking

Have you ever fallen (to the ground)?

YesNo

If yes, please describe?

How often do you fall?

Have you injured yourself?

Do you stumble, stagger, or side-step while walking?

YesNo

Do you drift to one side while you walk?

YesNo

If YES, to which side do you drift?

RightLeft

Do you have:

Rows	Yes	No
Diabetes
High blood pressure
Arthritis
Back problems
Hearing problems
Visual problems
Heart Disease
Headaches
Neck problems
Tinnitus (ear noise)
Stroke
Neurological issues

The scale below consists of a number of words that describe different feelings and emotions. Read each item and then indicate how you feel on average using the numbers 1 2 3 4 5.

Mark the number in the space next to the word. 1 = slightly/not at all 2 = a little 3 = moderately 4 = quite a bit 5 = extremely

Rows	Mark number here
interested
irritable
jittery
strong
nervous
enthusiastic
distressed
alert
active
excited
ashamed
afraid
upset
inspired
hostile
guilty
determined
proud
scared
attentive

Rows	Yes	No
Are you independent in self-care activities?
Can you drive: In the daytime?
Can you drive: In the night time?
Are you working?
Are you on Medical Disability?

If not applicable to the question: Are you working? Check here

Not Applicable

Are you able to:

Rows	Yes	No
Watch TV comfortably
Go shopping
Work on a computer
Scroll on a smart phone
Read hard copy
Be in Traffic
Be in a noisy place
Multi-task effectively

Do you live alone?

YesNo

If NO, who lives with you?

Do you have stairs in your home?

YesNo

If YES, how many?

Do you have trouble sleeping?

YesNo

For the following, please pick the one statement that best describes how you feel?

Negligible symptomsBothersome symptomsPerforms usual work duties but symptoms interfere with outside activitiesSymptoms disrupt performance of both usual work duties and outside activitiesCurrently on medical leave or had to change jobs because of symptomsUnable to work for over one year or established permanent disability with compensationpayments

VESTIBULAR ASSESSMENT - QUESTIONNAIRE

Past Medical History

Functional Status

Initial Visit