Microsoft word - audiology questionnaire.doc

Adventist Health Balance and Mobility Center
10201 SE Main Street Suite 4
Appointment Date:____________________________ Insurance:___________________________________ Portland OR 97216
(503) 251-6350
TIME IN:_______________ TIME OUT:_____________ Patient Questionaire

Instructions: Please complete the questions as best as you can and bring with
you on the day of your appointment. The information will assist us in making your
appointment as effective as possible. If you would like to return it ahead of time, please
mail it to the address listed above.
Personal Information:

Date form was completed: _____________________
Name:________________________________________________________________
Address:_______________________________________________________________
______________________________________________________________________
Home phone:________________________
Date of Birth:________________________
Occupation:_____________________________________
Primary Care Physician:__________________________________________
Address:_______________________________________________________________
Phone:________________________________________
Referring Physician:____________________________________________
Address:_______________________________________________________________
Phone:________________________________________
The Problem……………………………………………………………

Briefly state the problem for which you are seeking help:
When did your symptoms or similar symptoms FIRST begin (no matter how long ago)?
Describe in as much detail as you can what happened (use back if need more room):
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T:\Rehab Services\Website\Balance & Mobility Center\Audiology Questionnaire.doc (Description of first symptoms, continued…) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ______________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ T:\Rehab Services\Website\Balance & Mobility Center\Audiology Questionnaire.doc When did you last notice your symptoms? How do you feel today (please answer on day of appointment)? Have your symptoms changed since they first began? YES NO Are your symptoms with you 24 hours per day never stopping? YES NO If yes, check all symptoms that are present 24 hours per day never stopping: Do you have symptoms that occur in spells? YES NO If yes, check all symptoms that occur in spells (no matter how long the spell): Check the one that, on the average, describes how long the symptoms last: Measured in minutes to hours but less than 24 hours Measured in hours to days but less than 7 days Measured in days, can last continuously for weeks Check the one that, on the average, describes how frequently your symptoms occur: T:\Rehab Services\Website\Balance & Mobility Center\Audiology Questionnaire.doc Do you ever have symptoms occur when you are sitting, standing, or lying completely still, NOT having just moved and NOT watching anything that is moving? YES NO If yes, check all symptoms that occur in this spontaneous manner: Do you ever have symptoms that are brought on by you making a movement or a change in position? YES NO If yes, check all symptoms that occur with you movements or position changes: Are your symptoms made worse by any of the following? (Check all that apply) ASSOCIATED SYMPTOMS AND PROBLEMS
Check all the following symptoms that you have experienced: Sensation of being pulled or pushed down Loss of consciousness (blacked out) Nausea and/or vomiting Double vision (side by side or up down) Vision “jumping” when walking or riding Panic feeling – sudden need to leave a place
Circle the above symptoms that occurred with dizziness/imbalance
THE NEXT PAGE DEALS WITH HEADACHES. COMPLETE THE QUESTIONS AS
INDICATED EVEN IF YOU DO NOT FEEL HEADACHES ARE A CONCERN.
T:\Rehab Services\Website\Balance & Mobility Center\Audiology Questionnaire.doc Headaches…………………………………………………………….

Have you had a total of 5 or more headaches (no matter how severe) in your lifetime?
YES NO
Have you ever had a headache that was severe enough to make you stop your activity
and sit or lie down? YES NO
Have you ever experienced a temporary change in your vision, such as jagged lines,
color spots or lightening bolts? YES NO
Have you ever experienced a loss of vision in one or both eyes? YES NO
If you answered NO to all three questions above, please skip to the section on
HEARING.
If you answered YES to any of the three questions above, please continue with
the next questions:
Please check all of the following that you have experienced:
Headaches where the discomfort localizes to a region(s) of the head Increased sensitivity to light during a headache Increased sensitivity to sound during a headache Increased sensitivity to odors during a headache A headache provoked by a sudden bright light, such as sunlight Increased chance of headache around menstral cycle (females only) Change in headache behavior with pregnancy or after Certain foods or beverages increase the chances of a headache Motion sickness as a young child prior to puberty Nausea and/or vomiting with a headache Headache that lasted longer than 24 hours Headaches associated with your problems of dizziness or imbalance Headaches where the pain throbs or pulses If having headaches, at what age do you first remember having a headache? In your 50’s In your 60’s, 70’s or 80’s T:\Rehab Services\Website\Balance & Mobility Center\Audiology Questionnaire.doc Hearing…………………………………………………………………. Check all of the following that apply to you: I think I have a hearing loss, but this is not confirmed by testing. I have a documented hearing loss: In my left ear In my right ear In both ears My hearing changes from day to day (good some days, worse others) I have ringing or noise that I hear: In my left ear In my right ear In both ears all the time only in quiet off and on What rating would you give the pain in your ear(s) on a scale from 1-10 (1 little pain; 10 horrible pain) I have frequent infections/drainage from my ear(s): In my left ear In my right ear In both ears all the time Other disorders………………………………………………………. Do you currently have or have you been diagnosed in the past with any of the following? T:\Rehab Services\Website\Balance & Mobility Center\Audiology Questionnaire.doc Hospitalizations and injuries………………………………………… Have you been in the hospital for or had any of the following injuries? Hospitalized for treatment of an infection with antibiotic therapy Surgery on either ear OTHER MEDICAL AND SOCIAL HISTORY
Please indicate what tests you have had for your problem. Check all that apply: Test T:\Rehab Services\Website\Balance & Mobility Center\Audiology Questionnaire.doc Social and Family History….………………………………………… Please check all that apply to you: I smoke I drink beverages with caffeine I drink alcoholic beverages I live alone I have a history of use of “recreational drugs” I have repeated direct exposure to loud noises ……. Please check all that apply to your family members: (please write in who has these symptoms) Medications………………….………………………………………… Please attach or list below a COMPLETE LIST of (1) current prescription and over-the-counter medications you are taking and (2) medications you have tried in the past for your symptoms. Medication: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ T:\Rehab Services\Website\Balance & Mobility Center\Audiology Questionnaire.doc COMPUTERIZED DYNAMIC POSTUROGRAPHY
Computerized Dynamic Posturography (CDP) Assesment of balance function under differing
conditions and identification of patterns that aid in diagnosis. Your brain receives balance and
orientation information from three systems: eyes, inner ear, and body. This test helps us pinpoint
which information pathway is in error or missing by systematically eliminating each one. The
test is approximately 25 minutes in length.
CDP is a three-part evaluation. You will be secured into a vest/harness and then asked to stand
on a platform. The CDP evaluates body sway, center of gravity and the ability to compensate for
motion.
YOU SHOULD NOT POSTPONE THIS TEST IF YOU ARE SYMPTOMATIC.

To prepare for the test, you must avoid all generic and herbal versions of the medications listed
below for 48 hours prior to testing:

Antihisamines:
Chlortrimeton, Benedryl, Dimatane
Dizziness:
Antivert, Dramamine, Meclizine, Marezine, Bonine, Scopolamine,
Phenergran
Sedatives:
Dalmane, Seconal, Nembutal, Phenobarbital
Tranquilizers:
Valium, Librium, Tranxene, Meprobamate, Ativan, Xanax

DO NOT: DISCONTINUE MEDICATIONS THAT HAVE
BEEN PRESCRIBED FOR DIABETES, HEART
CONDITIONS, SEIZURES, OR BLOOD PRESSURE.
AVOID CAFFEINE, ALCOLHOL AND SMOKING FOR 24
HOURS PRIOR TO TESTING.
WOMEN PLEASE WEAR SLACKS.
I have read and understand the above contents and agree to the test ordered.
Signed______________________________ Date_____________________

T:\Rehab Services\Website\Balance & Mobility Center\Audiology Questionnaire.doc VIDEONYSTAGMOGRAPHY

Videonystagmography (VNG) helps determine if there are problems with the balance
system within the inner ear. A disorder of the balance mechanism results in small eye jerks
(nystagmus) which are picked up by an infrared camera that is attached to a set of goggles. The
VNG test is a four-part evaluation. which records eye jerks or nystagmus. The first series of tasks
consists of looking back and forth at different points and tracking moving lights. The second part
requires you to shake your head. The third part consists of lying down and sitting up quickly and
lying in different positions. The last portion of the test requires putting cool and warm air into the
ear canal for approximately 40 seconds to determine if the balance mechanism increases and
decreases normally in the response to temperature stimulation. This portion of the test often
causes you to feel as if you are spinning for approximately 2-5 minutes. This is a common
reaction. If you have concerns regarding residual dizziness please make arrangements for
someone to transport you. The test will take approximately one hour.

Preparing for the evaluation:

• You must avoid all generic and herbal versions of the medications listed below for at
least 48 hours prior to testing:
Antihisamines: Chlortrimeton, Benedryl, Dimatane
Dizziness:
Antivert, Dramamine, Meclizine, Marezine, Bonine,
Scopolamine, Phenergran
Sedatives:
Dalmane, Seconal, Nembutal, Phenobarbital
Tranquilizers: Valium, Librium, Tranxene, Meprobamate, Ativan, Xanax
• Do not drink coffee, tea, soda or any beverage containing caffeine or alcohol for at
least 24 hours prior to testing.
• Eat lightly on the day of the test.
• Women please do not wear mascara or eyeliner on the day of testing. The camera
used to record eye movements is sensitive to dark eye makeup.

DO NOT DISCONTINUE MEDICATIONS THAT HAVE BEEN PRESCRIBED FOR
DIABETES, HEART CONDITIONS, SEIZURES, OR BLOOD PRESSURE.

I have read and understand the above contents and agree to the test ordered.

Signed______________________________________Date_________________
T:\Rehab Services\Website\Balance & Mobility Center\Audiology Questionnaire.doc

Source: http://www.adventisthealthnw.com/amcp_resources/ccurl/371/328/audiology_questionnaire.pdf