Vestibular Medical History Questionnaire Posted on January 10, 2025 by Coastal Carolina Otolaryngology Step 1 of 4 25% PRETEST INSTRUCTIONS FOR VIDEO-NYSTAGMOGRAPHY (VNG) You have been scheduled to have special testing to determine the cause of your symptoms. This information is necessary for us to reach a diagnosis and determine the proper course of treatment for you. The balance system consists of input from three pathways—the eyes, or visual pathway; the proprioceptive pathway, or the sense of where your body is in space; and the ears, or vestibular pathway. VIDEO-NYSTAGMOGRAPHY: This test is done to determine the condition of the balance portion of the inner ear. It helps in diagnosing the cause of dizziness and related conditions. The VNG takes about one hour. Please dress comfortably and DO NOT WEAR EYE MAKEUP. This test consists of three parts—a visual tracking test that measures movements of the eyes as they follow a target, positional testing and caloric tests that measure the functionality of your inner ear system. 48 HOURS PRIOR TO TESTING: Discontinue the following medications if new within the last year (consult your prescribing physician if you have any concerns). ANTI-NAUSEA: Compazine, Dramamine®, Phenergan, Atarax, Thorazine, etc. ANTI-VERTIGO: Antivert, Meclizine, Bonine®, Robinul, Dramamine®, MotionEaze, Unisom®, Scopolamine patch, etc. ANTI-DEPRESSANTS, ANTI-ANXIETY: Xanax, Valium, Librium, Vistaril, Serax, Ativan, Librax, TRANXENE®, EFFEXOR XR®, Diazepam, Zoloft, Paxil, Wellbutrin, Lexapro, Prozac, Lorazepam, Cymbalta, Clonazepam, Ambien, Lunesta NARCOTICS & BARBITUATES: Demerol, Phenaphen, TYLENOL® with Codeine, Darvocet, Oxycodone, Percocet ANTI-HISTAMINES: Actifed, BENADRYL®, Chlor-Trimeton, Dimetane, Disophrol, Teldrin, Triaminic®, Claritin®, Clarinex, ZYRTEC®, Allegra®, Astelin and other over-the-counter cold remedies HERBS: Melatonin, Ephedra, Mu Huang, Ginkgo, St. John’s Wort, Kava, Valerian ANY SUBSTANCE THAT AFFECTS THE CENTRAL NERVOUS SYSTEM ALCOHOL in any quantity, including beer, wine and cough medicines with alcohol 24 HOURS before testing, avoid caffeine (coffee, tea and sodas), tobacco products and cigarettes If you are unable to follow these instructions, please call us prior to the testing or inform us when you arrive for the testing. It affects our interpretation of the test results. DO NOT EAT ANYTHING FOUR HOURS BEFORE TESTING. If you have any questions, call the audiology department at (843) 449-6449.Your appointment day is:MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your appointment time is: Hours : Minutes AM PM AM/PM Vestibular Medical History QuestionnaireName First Last Date of Birth MM slash DD slash YYYY Email Today's Date MM slash DD slash YYYY ENT/Physician ReferredInitial OnsetDescribe what happened the first time you experienced dizzy/imbalance symptoms:SymptomsPlease check all that apply. Dizziness Visual changes Falling Hearing loss Fatigue Nausea/Vomiting Spinning Double vision Lightheadedness Headache Brain fog Noise in ears Fullness, pressure or pain in ears Unsteadiness Rocking/Tilting Fainting History of Present Illness Describe your current problem:When did your problem start (date)?Was it associated with a related event (e.g., head injury)? Yes No If yes, please explain:Was the onset of your symptoms Sudden Gradual Overnight Other Please describe:Are your symptoms: Constant Variable (i.e., come and go in spells) The spell occurs every number of: HoursThe spell occurs every number of: DaysThe spell occurs every number of: WeeksThe spell occurs every number of: MonthsThe spell occurs every number of: YearsThe spell lasts Seconds Minutes Hours Days Do you have any warning signs that a spell is about to happen? Yes No If yes, please describe:Are you completely free of symptoms between spells? Yes No Do your symptoms occur when changing positions? Yes No If yes, check all that apply: Rolling your body to the left Rolling your body to the right Moving from a lying to a sitting position Looking up with your head back Turning head side to side while sitting/standing Bending over with your head down Is there anything that makes your symptoms better? Yes No If yes, please explain:Is there anything that makes your symptoms worse? Yes No If yes, check all that apply: Moving your head Riding/Driving in a car Loud sounds Standing up Time of day Physical activity or exercise Large crowds or busy environments Coughing, blowing nose Eating certain foods Stress When you have symptoms, do you need to support yourself to stand or walk? Yes No If yes, how do you support yourself?Have you ever fallen as a result of your current problem? Yes No Do you have a history of any of the following? Check all that apply. Migraines Multiple sclerosis Panic attacks/Anxiety Glaucoma Seizures Neuropathy Depression Macular degeneration Tumor Congestive heart failure Cervical spine arthritis Parkinson’s disease Stroke Concussion Diabetes mellitus Ataxia Has there been a recent change in your vision, including contacts or glasses? Yes No Describe any ear-related symptoms.Do you have any difficulty with hearing? Yes No If yes, which ear(s)? Left Right Both When did this start?Do your ear symptoms occur at the same time as your dizziness/imbalance symptoms? Yes No When you are walking, do you: Veer left? Veer right? Remain on a straight path? HabitsPlease describe your habits in regard to the following substances:Caffeine I do not consume caffeine I consume caffeine. Caffeine Frequency I drink cups of (e.g., coffee) per (time period) Tobacco I do not consume tobacco. I consume tobacco. Tobacco Frequency I smoke/chew (amount) of (product) per (time period) Alcohol I do not consume alcohol. I consume alcohol. Alcohol Frequency I drink glasses of (e.g., wine) per (time period) Recreational drug use I do not use drugs. I use drugs. I use: If selected 'I use drugs'How many times per day? If selected 'I use drugs'For how many years? If selected 'I use drugs'Medications I do not take any medications. I take medications. I take the following medications. If selected 'I take medications'
