What Causes Dizziness? Assessing Your Symptoms

Name*
FirstLast
Email
Phone
D.O.B*
When did your dizziness begin?*
Currently, my dizziness... (Check ALL that apply)*
- Is constant.
- Is constant but waxes and wanes.
- Comes and goes.
On average, how often does dizziness occur?*
- More than once a day
- Every... (click to see options)
- couple of hours
- couple of days
- week
- month
- couple of months
On average, how often does each dizzy spell last?*
- Seconds
- Minutes
- Hours
My dizziness consists mostly of... (Check ALL that apply)*
- Spells of spinning with nausea
- Off-balance sensation
- Light-headed or near-faint
- Other: please explain below
Between episodes I feel*
- Dizzy or off-balance all the time
- Normal
- Other: please explain below
Dizziness usually occurs:*
- When I turn my head too quickly or in certain directions
- Spontaneously; nothing specifically brings them on
- Other: please explain below
When I roll over in bed...*
- The room seems to spin every time
- The room seems to spin sometimes
- Nothing usually happens
Overall functional level scale*
- My dizziness has no effect on my activities at all
- When I am dizzy I gave to stop what I am doing for a while, but it soon passes and I can resume activities. I continue to work, drive, and engage in any activity I choose without restriction. I have not changed any plans or activities to accomodate my dizziness.
- When I am dizzy I have to stop what I am doing for a while, but it does pass and I can resume activities. I continue to work, drive, and engage in most activities I choose, but I have had to change some plans and make some allowances for my dizziness.
- I am able to work, drive, travel, take care of a family, or engage in most essential activities, but I must exert a great deal of effort to do so. I must constantly make adjustments in my activities and budget my energies. I am barely making it.
- I am unable to work, drive, or take care of a family. I am unable to do most of the active things that I used to. Even essential activities must be limited, I am disabled.
- I have been disabled for one year or longer and/or I receive compensation (money) because of my dizziness or balance problem.
I would like a scheduler from your office to contact me:
- By Phone
- By Email
- I do not want to be contacted. I will contact you.
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What Causes Dizziness? Assessing Your Symptoms - Dizziness Treatment