Dizziness Questionnaire
Name Today’s Date
Date of Birth: Contact Number:
Describe the sensation as accurately as you can
When and under what circumstances did it begin?
Is the symptom continuous or does it come in bouts?
How often does an episode come on and how long does each episode last?
What brings it on or makes it worse?
What abolishes the symptom or makes it easier?
Are your sight or hearing affected during the episode?
Does anything else happen when you get the symptom?
What is the impact on your life on a score of 0 -10?
Do you lose consciousness, faint or feel as though you are going to faint?
Is there anything in going on in your life or in your life-style that could be contributing to the problem?
Are you more depressed or worried than usual?
Do you think the symptom is getting better or worse?
Do you know anyone or have you ever heard of anyone who has a similar problem like you?
Please list any tablets or treatments you are taking, including those not actually prescribed by a doctor.
Please express any opinions or secret fears that have been suggested or crossed your mind as the cause of the pain.
What are your hopes from today’s consultation?
Is there anything else I should know?
Bernard Shevlin
b.shevlin02@gmail.com