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Patient Name  _________________________________________ Date _____________
M/F  ______ Age  ______ Years of Education ________ Date of Injury ____________
Acute Symptoms __________________________________________________________
Employment (type)  ______________________________ Date of Return to Work  _____
 
 
A. Dizziness/Vertigo
  1. Have you experienced dizziness or lightheadedness since your accident?
  2. Did it ever feel as if the room was spinning around you?
      a. Do you become nauseous?  Have you vomited?
  3.  Are you dizzy all the time or does it come and go?
      What kinds of things make you dizzy?
        a. Looking up
        b. Rapid head movements
        c. Changes in position
        d. Watching things that are in motion
        e. Turning over in bed
        f. Rising up or sitting down
        g. Bending to pick something up
        h. Walking with your child or your dog
        i. Exercising
        j. Walking down a grocery store aisle?
        k. Being in a crowd of people?
        l. Looking over your shoulder while driving?
  4. Has your dizziness or vertigo improved over time?
  5. Have you become more cautious about how you move?
  6. Have you had to stop some of your regular activities?
         
B. Dysequilibrium/Imbalance
  1. Do you have problems with your balance?
  2. Have you had either blurred or double vision?
  3. When you get up from sitting, do you have to steady yourself?
  4. Have you fallen?
  5. Do you feel stable when you’re walking?
      a. Do you tend to lean or veer to one side?
      b. Do you bump into things on one side or the other?
  6. Would feel out of balance if you:
      a. Tried to run?
      b. Turned around quickly?
      c. Looked from side to side?
      d. Looked up?
      e. Looked down?
      f. Stood with your eyes closed?
      g. Went up or down stairs?
      f. Stood with your eyes closed?
  7. Does your equilibrium feel off even when you’re sitting?
     
C.  Visual Blurring/ Photophobia
  1. Have you experienced any problems with your vision since your accident?
  2. Have you had either blurred or double vision?
  3. Is it difficult to stay focused for a long time?
  4. Does sustained focusing:
      a. Increase visual blurring?
      b. Cause dizziness and/or nausea?
      c. Result in a loss of concentration?
      d. Cause substantial fatigue?
      e. Provoke a headache?
  5. Have you had problems with photophobia or light sensitivity?
      a. Do you frequently wear dark glasses?
  6. Are you able to watch television comfortably?
  7. Do you enjoy going to the movies?
  8. Do you have problems when you look out the car window at things going by?
  9. Do you have difficulty with close visual work?
     
D.  Problems with Sustained Reading
  1. Since the accident, have your reading habits changed?
  2. Are you able to read as long as you used to?
  3. Can you read comfortably for a short time?
  4. If you try to read longer,
      a. Does your vision become more blurry?
      b. Do you lose your concentration?
      c. Do you get dizzy or nauseous?
      d. Do you become exhausted?
      e. Do you develop a headache?
  5. Does the type print ever appear unstable, fragmented or floaty?
  6. Do you have trouble with reading comprehension?
 
 
 
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