Vestibular Assessment

Name*

First Last

Date*

Referring Physician:

Describe the major problem or reason you are seeing us:

When did the problem begin?

Specifically, do you experience a sense of spinning (vertigo)?

Yes
No

How long do these spells last?

When was the last time the vertigo occured?

Is the vertigo:

Spontaneous

Yes
No

Induced by motion

Yes
No

Induced by position changes

Yes
No

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Do you experience a sense of being off balance (disequilibrium)?

Yes
No

Constant

Yes
No

Spontaneous

Yes
No

Induced my motion

Yes
No

Induced by position changes

Yes
No

Worse with fatigue

Yes
No

Worse in the dark

Yes
No

Worse outside

Yes
No

Worse on uneven surfaces

Yes
No

Does the feeling of being off balance occur when:

Lying down

Yes
No

Sitting

Yes
No

Standing

Yes
No

Walking

Yes
No

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Do you or have you fallen to the ground?

Yes
No

Please describe:

How often do you fall?

Have you injured yourself from a fall?

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

Yes
No

Do you drift to one side while you walk?

Yes
No

To which side do you drift?

Left
Right

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Have you been in an accident?

Yes
No

When did it occur?

Please describe:

Past Medical History

Do you have:

Diabetes

Yes
No

Headaches

Yes
No

Neck Problems

Yes
No

Back Problems

Yes
No

Arthritis

Yes
No

Heart Disease

Yes
No

Hypertension

Yes
No

Pulmonary Problems

Yes
No

Hearing Problems

Yes
No

Visual Problems

Yes
No

What medications are you currently taking?

Social History

Do you live alone?

Yes
No

Do you have stairs in your home?

Yes
No

Do you have trouble sleeping?

Yes
No

Functional Status

Are you independent in self-care activities?

Yes
No

Can you drive in the day time?

Yes
No

Can you drive at night?

Yes
No

Are your working?

Yes
No
N/A

Are you on medical disability?

Yes
No

Are you able to watch TV comfortably?

Yes
No

Are you able to go shopping?

Yes
No

Are you able to work on a computer?

Yes
No

Are you able to read?

Yes
No

Are you able to be in traffic?

Yes
No

Are you able to be in a noisy place?

Yes
No

Please pick one statement that best describes how you feel today:

My symptoms are negligible.
My symptoms are bothersome.
I am able to perform my usual work duties but my symptoms interfere with my participation/outside recreational activities.
My symptoms impede my performance in both my usual work duties and outside/recreational actviites.
I am currently on medical leave or have changed jobs because of my symptoms.
I have been unable to work for > 1 year and/or am receiving permanent long term disability payments.

Vestibular Assessment