DIZZINESS QUESTIONNAIRE

 

With thanks for this questionnaire to Dr Bernard Shevlin, a GP in Stoke on Trent

 

If you intend to come to see the doctor or nurse about dizziness, it might  help if you could print out and complete this questionnaire, and bring it along with you when you come to see your doctor.

If you are feeling Anxious or Depressed as well, it would help if you could also complete another questionnaire to bring- click here

 

Name        …………….                        Date of Birth......

Tel No    ………………                        Date

1. Describe your symptom as accurately as you can

2. When exactly did it start?         ...

 

3. Is it there all the time?          .......

 

4. Does anything bring it on or make it worse?

5. Does anything make it easier?

6. Are your sight or hearing affected?      ......

 

7. Do you lose consciousness or faint? .......

 

8. Please list any tablets or treatments you are currently taking
including those not actually prescribed by us.

9. Are you more depressed or worried than usual?

10. Is there anything in your lifestyle which could be contributing
to your problem?

 

 

11. Do you know of ANYONE
else having a similar problem?

 

 

 

12. Could you please express any opinions, theories or secret fears
that may have crossed your mind or been suggested as to the cause
of the pain.

13. Please describe in full any other symptoms

14. Is there anything else I should know?