Medical History Questionnaire Name: DOB: : Referring Physician: Primary Complaint: Dizziness Blacking out/fainting Lightheadedness Imbalance Falling Vertigo (spinning) Blurred Vision Unsteadiness Hearing Loss Ringing in the ears Ear Pain Headaches Nausea/Vomiting Tingling Hands/Feet/Lips Numb Feet Neck Pain Other: History of Symptoms: When did the first episode occur (date): The onset was -------------- Sudden -------- Gradual ---------- Overnight ----------- Others The progress of the symptoms are ------------ Getting better ---- Staying the same -- Worsening How frequent are the symptoms occur? ------ Constant --------- Intermittent Are your symptoms made worse by any of the following? Check all that apply: Lying down/rolling in bed Sitting up/standing up Walking in the dark Walking on uneven surfaces Coughing/sneezing/nose blowing Hot baths or showers Menstrual cycle (if applicable) Supermarket aisles/malls/tunnels Automobile rides Windshield wipers Loud sounds Restaurants or movie theaters Reading Turning your head when walking Exercise Reaching or bending Stress or nerves Is there anything else you know of that will provoke or make your dizziness worse? Do you have symptoms that occur in spell? ------------------------------------------------------------------------------------ Yes ---- No If yes, check all symptoms that occur in spells (no matter how long the spell): Off balance when standing or walking Light-headed or fainting sensation Off balance when sitting or lying down Tumbling or spinning sensation Check the one that (on the average) describes the length of the typical, single spell: Measured in seconds 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 ACMC-Marshall Market Street: 1420 East College Drive Marshall, MN 56258 (507) 532-1958 ACMC#1173 REV. 01/17 1
Check the one that (on the average) describes how frequently your spells are occurring: Daily or multiple times per day Several times in a 2-month interval Multiple times per week Several times in a 6-month intervals Multiple times per month Several times in a 12-month interval Do you use a cane, walker, or furniture/walls to keep your balance? ---------------------------------------------------------- Yes ---- No Does poor lighting affect your balance? ------------------------------------------------------------------------------------------- Yes ---- No Are uneven surfaces (grass, gravel, hills) difficult to negotiate? --------------------------------------------------------------- Yes ---- No Have you fallen because of these symptoms? ------------------------------------------------------------------------------------ Yes ---- No Number of falls: Number of Near-Falls : Do you tend to fall in one direction? ------------------------------------------------------------------------------------------------ Yes... No If yes, which direction? Do the symptoms seem to be related to your cycle? (if applicable) ------------------------------------------------------------ Yes ---- No If so, how? Are you currently pregnant? (if applicable) --------------------------------------------------------------------------------------- Yes ---- No Due : This section deals with headaches. It is important to complete it as indicated. Have you had a total of 5 or more headaches (does not 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 (jagged lines, color spots or lightning bolts)? ---------- Yes ---- No Have you ever been diagnosed with migraine headaches? ---------------------------------------------------------------------- Yes ---- No (If you have answered No to all four above, then go to the section on Vision. ) (If you have answered Yes to 1, 2, 3, or 4 above, then please complete section below.) 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 A headache provoked by a sudden bright light, such as sunlight Increased sensitivity to sound during a headache Increased chance of headache around your menses (if applicable) Increased sensitivity to odors during a headache Change in headache behavior with pregnancy or after (if applicable) Motion sickness as young child prior to puberty Certain foods or beverages increase the chances of a headache Nausea and/or vomiting with a headache Headaches associated with your problems of dizziness or imbalance Headache that lasted longer than 24 hours Headaches where the pain throbs or pulses At what age do you first remember having a headache? Under age 12 In your twenties or thirties In your fifties In your teens In your forties In your sixties, seventies od eighties Have headaches been a significant problem with the past 6 months? --------------------------------------------------------- Yes ---- No ACMC-Marshall Market Street: 1420 East College Drive Marshall, MN 56258 (507) 532-1958 ACMC#1173 REV. 03/23/17 2
Vision: Have you recently got new lenses? ------------------------------------------------------------------------------------------------- Yes ---- No Last eye exam: Has your vision changed as a result of your current symptoms? --------------------------------------------------------------- Yes ---- No Please describe: Hearing: Do you have any of the following ear symptoms? Loss of hearing? --------------------------------- Yes --------------- No ------------------- Which ear? Left --- Right - Both The progress of the symptoms are ------------ Getting better ---- Staying the same -- Worsening Wear hearing aids? ------------------------------ Yes --------------- No ------------------- Which ear? Left --- Right - Both Ringing/noise in your ears? -------------------- Yes --------------- No ------------------- Which ear? Left --- Right - Both How frequent are the symptoms occur? ------ Constant --------- Intermittent Have you ever had a hearing test done? ------------------------------------------------------------------------------------------- Yes ---- No If yes, --------------------------------------------- Where: When: Neurologic: Do you experience any of the following? Doubled or blurred vision Numbness of face/extremities Weakness in arms/legs Poor coordination in arms/legs Confusion or loss of consciousness Swallowing/Speech difficulties Evaluation, Treatment & Testing: Other healthcare providers you have seen for these symptoms: Surgery, procedures and/or therapy for these symptoms: Previous tests for these symptoms: Brain or Cervical Spine CT Scan --------- Where: When: Brain or Cervical Spine MRI/MRA ------ Where: When: ENG/VNG (Vestibular Testing) ---------- Where: When: Other: Allergies: (please describe reaction) Seasonal Allergies: Environmental Allergies (Dust / Latex): Drug Allergies: ACMC-Marshall Market Street: 1420 East College Drive Marshall, MN 56258 (507) 532-1958 ACMC#1173 REV. 03/23/17 3
Medications & Supplements: Medication/Supplement Dosage Times per day Start when? Self& Family Medical History: Diagnosis Self Mother Father Grandparent Alzheimer s Epilepsy/Seizures Parkinson s Multiple Sclerosis Panic Attacks Depression Anxiety Cancer/ Tumors Glaucoma Macular Degeneration Migraines Sleep Apnea Fibromyalgia Osteoporosis Arthritis Diabetes Thyroid disease High Blood Pressure Anemia Low Blood Pressure Heart Disease Irregular Heartbeat High Cholesterol Stroke / TIA Meniere s Disease Peripheral Neuropathy Sciatica Cataract If removed, when? Neck of onset? Explain: Low Back Pain of onset? Explain: Lower Extremity Joint Injury of onset? Explain: ACMC-Marshall Market Street: 1420 East College Drive Marshall, MN 56258 (507) 532-1958 ACMC#1173 REV. 03/23/17 4
Health History: Hospitalizations Surgeries Serious Injury/Illness Patient s Information Marital Status: ------- Single ----- Married/Divorced/Separated --- Widowed Occupation: Living Situation: ----- House ----- Apartment ---- Condo ------- Nursing Home ------ Assisted Living Stairs? ---------------------------------------------------------------------------------------------------------------------------------- Yes ---- No Who do you live with: --------------- Spouse -------- Family ------- Significant Other --- Alone -- Other: List your hobbies/activities: Please indicate your activity level: - Sedentary ----- Light --------- Moderate ------------ Vigorous Habits Caffeine ------------------------------------------- Yes --------------- No ------------------- Beverages per day: Smoking ------------------------------------------ Yes --------------- No ------------------- Cigarettes/packs per day: Alcohol ------------------------------------------- Yes --------------- No ------------------- Drinks per week/month: Recreational drug use --------------------------- Yes --------------- No ------------------- If so, what do you use? How often do you use it? times per day week --------------------- For how long? ACMC-Marshall Market Street: 1420 East College Drive Marshall, MN 56258 (507) 532-1958 ACMC#1173 REV. 03/23/17 5