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Fayetteville
Fayetteville
Address:
Lyndon Office Park,
7000 East Genesee Street
Fayetteville
,
NY
,
13066
,
Phone Number(s):
Office:
(315) 565-3250
Fax:
(315) 320-0245
Camillus
Camillus
Address:
5639 West Genesee Street
Camillus
,
NY
,
13031
,
Phone Number(s):
Office:
(315) 925-4839
Fax:
(315) 320-0245
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Patient Neurodiagnostic Intake Form
Patient Name
(Required)
First
Last
Patient Email
Date Of Birth
(Required)
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Provider Name
(Required)
Appt Date
(Required)
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Sex
(Required)
Male
Female
Current Symptoms
Which of the following best describes your symptoms?
(Required)
Imbalance
Falling more often
World spinning around you
You feel as if YOU are spinning; the world is not spinning
Nausea
Lightheadedness
Other Symptoms
How long do your symptoms last without stopping?
(Required)
Seconds
Minutes
Hours
Days
Symptoms are constant
How often do you have an episode?
(Required)
Example: 2 time(s) per day | 15 time(s) per year | 1 time(s) per month
Did any of the following occur prior to your symptom onset?
(Required)
Head trauma
Motor Vehicle Accident
Upper Respiratory Infection
Change in medication
A Fall
A virus or infection, e.g., Shingles, Cold Sores, COVID-19
Surgery
Stressful event or high stress
Other precursors
How have your symptoms changed since they began?
(Required)
They’ve stayed the same
They’ve Improved
They’ve Changed
If Improved or Changed: How so?
Does anything make your symptoms better?
(Required)
Balance & Fall Symptoms
Have you fallen in the past year?
(Required)
Yes
No
If yes: How many times?
If no: Have you experienced "near falls" but you caught yourself?
Yes
No
Are you afraid of falling?
(Required)
Yes
No
Are you veering/leaning while walking?
(Required)
Yes
No
If yes: Which direction?
Right
Left
Both
Do you have neuropathy, numbness, or tingling in your feet or legs?
(Required)
Yes
No
Has your exercise decreased?
(Required)
Yes
No
If yes: Approximately when?
Orthopedic injuries?
(Required)
Yes
No
If yes: Please explain
Dizziness Symptoms
Do you have a history of Migraines?
(Required)
Yes
No
If yes: When was your most recent Migraine?
Do any of the following trigger your symptoms?
(Required)
Increased stress
Skipping a meal
Not drinking enough water
Changes in weather
Certain foods
Check all that apply
If you selected Certain foods: What foods trigger your symptoms?
Do any of the following accompany or occur immediately prior to an episode of your symptoms?
(Required)
Headaches
Neck Pain
Hearing Loss (Right Ear)
Hearing Loss (Left Ear)
Fullness in your ear(s) (Right Ear)
Fullness in your ear(s) (Left Ear)
Ringing in your ear(s) (Right Ear)
Ringing in your ear(s) (Left Ear)
Shimmers or Sparkles in your Vision
Sensitivity to light
Sensitivity to sound
Sensitivity to smell
Check all that apply
My dizziness is intense but only lasts for seconds or minutes
(Required)
Yes
No
I get dizzy when I turn over in bed
(Required)
Yes
No
I get short-lasting, spinning dizziness that happens when I bend down to pick something up
(Required)
Yes
No
I get short-lasting, spinning dizziness that happens when I go from sitting to lying down
(Required)
Yes
No
I can trigger my dizzy spells by placing my head in certain positions
(Required)
Yes
No
I have had a single severe spell of spinning dizziness that lasted for hours to a day
(Required)
Yes
No
After my big episode of dizziness, I could not walk for days without falling over
(Required)
Yes
No
I had a spell of spinning dizziness that lasted for hours after I had a cold, virus, or flu
(Required)
Yes
No
I had hearing loss in one ear at the same time I had the long episode of spinning dizziness
(Required)
Yes
No
I have spells where I get dizzy, and it is difficult for me to breathe
(Required)
Yes
No
I feel dizzy all of the time
(Required)
Yes
No
I am anxious most of the time
(Required)
Yes
No
I am bothered by patterns, screens, e.g., supermarkets
(Required)
Yes
No
My symptoms increase when I go from laying to sitting or sitting to standing
(Required)
Yes
No
When I cough or sneeze, I get dizzy
(Required)
Yes
No
I get dizzy when I strain to lift something heavy
(Required)
Yes
No
When I speak, my voice sounds abnormally loud to me
(Required)
Yes
No
My dizziness is provoked with head movements (up/down and/or right/left)
(Required)
Yes
No
My head is heavy like a bowling ball
(Required)
Yes
No
I have a headache that is in or starts in the back of my head
(Required)
Yes
No
When I sit up from lying down, or stand up from sitting, I experience a few seconds of dizziness
(Required)
Yes
No
Medical History
Are your Blood Sugar, Blood Pressure, and Thyroid Levels well controlled?
(Required)
Yes
No
Do you have any known eye/vision issues?
(Required)
Yes
No
If yes: Please explain
Do you have hearing loss?
(Required)
Yes
No
If yes: Which ear?
Right ear
Left ear
Both ears
If yes: Was it sudden?
Yes
NO
Do you wear hearing aids?
Yes
No
I am experiencing…
(Required)
…Pain
…Ringing
…Drainage
…Fullness
Select all that apply
If yes: Which ear(s)?
Right ear
Left ear
Both ears
If Applicable: Female Hormonal History
Which of these apply?
Pre-Menopausal
Peri-Menopausal
Post-Menopausal
Did you have a hysterectomy?
Yes
No
If yes: When?
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Have you had any changes in your contraceptives?
Yes
No
If yes: When?
Month
Day
Year
Do you have known hormonal imbalance?
Yes
No
If yes: Are you being treated for this issue?
Yes
No