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Patient Neurodiagnostic Intake Form

Patient Name(Required)
Date Of Birth(Required)
Appt Date(Required)
Sex(Required)

Current Symptoms

Which of the following best describes your symptoms?(Required)
How long do your symptoms last without stopping?(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)
How have your symptoms changed since they began?(Required)

Balance & Fall Symptoms

Have you fallen in the past year?(Required)
If no: Have you experienced "near falls" but you caught yourself?
Are you afraid of falling?(Required)
Are you veering/leaning while walking?(Required)
If yes: Which direction?
Do you have neuropathy, numbness, or tingling in your feet or legs?(Required)
Has your exercise decreased?(Required)
Orthopedic injuries?(Required)

Dizziness Symptoms

Do you have a history of Migraines?(Required)
Do any of the following trigger your symptoms?(Required)
Check all that apply
Do any of the following accompany or occur immediately prior to an episode of your symptoms?(Required)
Check all that apply
My dizziness is intense but only lasts for seconds or minutes(Required)
I get dizzy when I turn over in bed(Required)
I get short-lasting, spinning dizziness that happens when I bend down to pick something up(Required)
I get short-lasting, spinning dizziness that happens when I go from sitting to lying down(Required)
I can trigger my dizzy spells by placing my head in certain positions(Required)
I have had a single severe spell of spinning dizziness that lasted for hours to a day(Required)
After my big episode of dizziness, I could not walk for days without falling over(Required)
I had a spell of spinning dizziness that lasted for hours after I had a cold, virus, or flu(Required)
I had hearing loss in one ear at the same time I had the long episode of spinning dizziness(Required)
I have spells where I get dizzy, and it is difficult for me to breathe(Required)
I feel dizzy all of the time(Required)
I am anxious most of the time(Required)
I am bothered by patterns, screens, e.g., supermarkets(Required)
My symptoms increase when I go from laying to sitting or sitting to standing(Required)
When I cough or sneeze, I get dizzy(Required)
I get dizzy when I strain to lift something heavy(Required)
When I speak, my voice sounds abnormally loud to me(Required)
My dizziness is provoked with head movements (up/down and/or right/left)(Required)
My head is heavy like a bowling ball(Required)
I have a headache that is in or starts in the back of my head(Required)
When I sit up from lying down, or stand up from sitting, I experience a few seconds of dizziness(Required)

Medical History

Are your Blood Sugar, Blood Pressure, and Thyroid Levels well controlled?(Required)
Do you have any known eye/vision issues?(Required)
Do you have hearing loss?(Required)
If yes: Which ear?
If yes: Was it sudden?
Do you wear hearing aids?
I am experiencing…(Required)
Select all that apply
If yes: Which ear(s)?

If Applicable: Female Hormonal History

Which of these apply?
Did you have a hysterectomy?
If yes: When?
Have you had any changes in your contraceptives?
If yes: When?
Do you have known hormonal imbalance?
If yes: Are you being treated for this issue?