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Hand Dominance
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If ambidextrous provide details.
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I am seeing a specialist.
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Which specialists do you see?
• • •
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Where did you find us?
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Who referred you?
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Anything special we need to know?
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Vestibular Health History
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I have now or have had in the past dizziness, vertigo or balance issues.
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Answer the following as they relate to dizziness or balance complaints.
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Describe your complaint in your own words w/o using the word “dizzy.”
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Check all that apply to balance complaint.
• • •
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If "other", describe briefly
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Have you seen anyone else for this complaint?
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If "yes", who have you seen?
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If "yes," what treatments have you received?
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Ever experienced this type of problem before?
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If "yes," what were the outcomes of treatment?
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Have you seen anyone in the past regarding your dizziness?
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Who did you see in the past regarding your dizziness?
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If "yes" answered, when and how many times?
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If "yes," what were the outcomes of treatment?
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What treatments did you receive?
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Do you ever experience the following sensations?
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"Spinning in circles"?
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If, "Yes," describe the direction
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"Falling to one side"?
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If, "Yes," describe the direction
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The world is spinning around you.
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If, "Yes," describe the direction
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You are spinning around the world.
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If, "Yes," describe the direction
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Any falls due to these symptoms?
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If you have fallen, have you been injured?
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If injured in fall described above, explain.
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Leave Blank for Doctor's Note
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Answer the following about a typical "dizzy" spell:
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When did you notice your first dizzy spell (i.e. date)?
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Describe where you were and how your first dizzy spell came on
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Description:
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Any Rx's or OTC's or other meds taken B4 symptoms came on?
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If yes, describe
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Does anything trigger the onset of your dizzy spells?
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If yes, explain
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Have you had a recent cold or flu prior to your recent dizzy spells?
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Do these dizzy spells come in attacks?
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How often do dizzy spells occur?
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How long do these dizzy spells last?
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What time of day do these dizzy spells occur?
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Completely free of dizziness between attacks?
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Does it occur mainly when you sit up or stand up too quickly?
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What positions are you mainly dizzy in?
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Are you dizzy even when lying down?
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Do you have difficulty getting into bed?
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Leave Blank for Doctor's Note
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Metabolic Assessment
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Category I: CH
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Feeling that bowels do not empty completely
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Lower abdominal pain relieved by passing stool or gas
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Alternating constipation and diarrhea
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Diarrhea
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Constipation
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Hard, dry, or small stool
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Coated tongue or “fuzzy” debris on tongue
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Pass large amount of foul-smelling gas
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More than 3 bowel movements daily
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Use laxatives frequently
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Category II: HC
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Excessive belching, burping or bloating
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Gas immediately following a meal
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Offensive breath
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Sense of fullness during and after meals
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Difficult bowel movements
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Difficulty digesting fruits and vegetables; undigested foods found in stools
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Category III: HA
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Stomach pain, burning or aching 1-4 hours after eating
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Use antacids
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Feel hungry and hour or two after eating
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Heartburn when lying down or bending forward
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Temporary relief by using antacids, food, milk or carbonated beverages
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Digestive problems subside with rest and relaxation
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Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol and caffeine
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Category IV: SI
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Roughage and fiber cause constipation
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Indigestion and fullness last 2-4 hours after eating
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Pain, tenderness, soreness on left side under rib cage
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Excessive passage of gas
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Nausea and/or vomiting
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Frequent urination
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Stool undigested, foul smelling, mucous like, greasy, or poorly formed
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Increased thirst and appetite
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Difficulty losing weight
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Category V: BT
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Greasy or high fat foods cause distress
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Lower bowel gas and/or bloating several hours after eating
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Bitter metallic taste in mouth, especially in the morning
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Unexplained itchy skin
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Yellowish cast to eyes
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Stool color alternates from clay colored to normal brown
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Reddened skin, especially palms
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Dry or flaky skin and/or hair
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History of gallbladder attacks or stones
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Have you had your gall bladder removed?
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Category VI: HO
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Crave sweets during the day
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Irritable if meals are missed
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Depend on coffee to keep going/get started
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Get light-headed if meals are missed
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Eating relieves fatigue
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Feel shaky, jittery or have tremors
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Agitated, easily upset, nervous
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Poor memory/forgetful
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Blurred vision
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Category VII: IR
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Fatigue after meals
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Crave sweets during the day
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Eating sweets does not relieve cravings for sugar
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Must have sweets after meals
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Waist girth is equal to or larger than hip girth
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Frequent urination
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Increased thirst and appetite
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Difficulty losing weight
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Category VIII: AF
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Cannot stay asleep
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Crave salt
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Slow starter in the morning
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Afternoon fatigue
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Dizziness when standing up quickly
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Afternoon headaches
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Headaches with exertion or stress
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Weak nails
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Category IX: AH
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Cannot fall asleep
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Perspire easily
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Under high amount of stress
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Weight gain when under stress
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Wake up tired even after 6 or more hours of sleep
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Excessive perspiration or perspiration with little or no activity
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Category X: HoT
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Tired/sluggish
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Feel cold--hands, feet, all over
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Require excessive amounts of sleep to function properly
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Increase in weight even with low calorie diet
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Gain weight easily
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Difficult, infrequent bowel movements
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Depression/lack of motivation
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Morning headaches that wear off as the day progresses
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Outer third of eyebrow thins
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Thinning of hair on scalp, face, or genitals; excessive hair loss
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Dryness of skin and/or scalp
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Mental sluggishness
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Category XI: Thr
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Heart palpitations
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Inward trembling
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Increased pulse even at rest
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Nervous and emotional
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Insomnia
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Night sweats
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Difficulty gaining weight
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Category XII: Pho
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Diminished sex drive
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Menstrual disorders or lack of menstruation
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Increased ability to eat sugars without symptoms
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Category XIII: Phr
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Increased sex drive
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Tolerance to sugars reduced
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“Splitting”-type headaches
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Male Patients, Please Switch button to "On" and Fill Out
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Category XIV: PH
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Urination difficulty or dribbling
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Frequent urination
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Pain inside of legs or heels
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Feeling of incomplete bowel emptying
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Leg twitching at night
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Category XV: AP
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Decreased libido
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Decreased number of spontaneous morning erections
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Decreased fullness of erections
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Spells of mental fatigue
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Inability to concentrate
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Episodes of depression
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Muscle soreness
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Decreased physical stamina
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Unexplained weight gain
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Increase in fat distribution around chest and hips
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Sweating attacks
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More emotional than in past
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Menstruating Females Only switch button to "On" and fill out.
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Category XVI
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Premenopausal
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Alternating menstrual cycle lengths
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Extended menstrual cycle (greater than every 32 days)
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Shortened menstrual cycle (less than every 24 days)
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Pain and cramping during periods
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Scanty blood flow
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Heavy blood flow
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Breast pain and swelling during menses
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Pelvic pain during menses
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Irritable and depressed during menses
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Acne
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Facial hair growth
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Hair loss/thinning
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Menopausal Females Only switch button to "On" and fill out.
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Category XVII
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How many years have you been menopausal?
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Since menopause, do you ever have uterine bleeding?
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Hot flashes
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Mental fogginess
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Disinterest in sex
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Mood swings
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Depression
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Painful intercourse
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Shrinking breasts
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Facial hair growth
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Acne
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Increased vaginal pain, dryness or itching
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Neurological Assessment
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Section 1 BE
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A decrease in attention span
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Mental fatigue
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Difficulty learning new things
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Difficulty learning new things
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Difficulty concentrating and staying focused for extended periods of time
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Experiencing fatigue when reading sooner than in the past
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Experiencing fatigue when driving sooner than in the past
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Need for caffeine to stay mentally alert
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Overall brain function impairs your daily life
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Section 2 BMC
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Twitching or tremor in your hands and legs when resting
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Handwriting has gotten smaller and more crowded together
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A loss of smell to foods
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Difficulty sleeping or falling asleep
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Stiffness in shoulders and hips that goes away when you start to move
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Constipation
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Voice has become softer
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Facial expression that is serious or angry
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Episodes of dizziness or light-headedness upon standing
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A hunched over posture when getting up and walking
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Section 3 MCF
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Memory loss that impacts daily activities
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Difficulty planning, problem solving, or working with numbers
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Difficulty completing daily tasks
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Confusion about dates, the passage of time, or place
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Difficulty understanding visual images and spacial relationships (addresses and locations)
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Difficulty finding words when speaking
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Misplacement of things and inability to retrace steps
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Poor judgment and bad decisions
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Disinterest in hobbies, social activities, or work
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Personality or mood changes
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Section 4 TLF
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Reduced function in overall hearing
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Difficulty understanding language with background or scatter noise
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Ringing or buzzing in the ear
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Difficulty comprehending language without perfect pronunciation
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Difficulty recognizing familiar faces
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Changes in comprehending the meaning of sentences, written or spoken
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Difficulty with verbal memory and finding words
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Difficulty remembering events
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Difficulty recalling previously learned facts and names
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Inability to comprehend familiar words when read
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Difficulty spelling familiar words
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Monotone, unemotional speech
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Difficulty understanding the emotions of others when they speak (nonverbal cues)
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Disinterest in music and lack of appreciation of melodies
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Difficulty with long-term memory
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Memory impairment when doing the basic activities of daily living
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Difficulty with directions and visual memory
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Noticeable difference in energy levels throughout the day
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Section 5 OLF
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Difficulty coordinating visual inputs and hand movements resulting in an inability to efficiently reach for objects
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Difficulty comprehending written text
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Floaters or halos in your visual field
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Dullness of colors in your field during different times of day
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Difficulty discriminating similar shades of color
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Section 6 FCF
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Difficulty with detailed hand coordination
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Difficulty with making decisions
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Difficulty with suppressing socially inappropriate thoughts
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Socially inappropriate behavior
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Decisions made based on desires, regardless of the consequences
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Difficulty planning and organizing daily events
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Difficulty motivating yourself to start and finish tasks
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A loss of attention and concentration
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Section 7 PLF
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Hypersensitivities to touch or pain
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Difficulty with spatial awareness when moving, laying back in a chair, or leaning against a wall
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Frequently bumping into the wall or objects
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Difficulty with right-left discrimination
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Handwriting has become sloppier
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Difficulty with basic math calculations
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Difficulty finding words for written or verbal communication
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Difficulty recognizing symbols, words, or letters
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Insomnia
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Section 8 PMF
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Difficulty swallowing supplements or large bites of food
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Bowel motility and movements slow
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Bloating after meals
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Dry eyes or dry mouth
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A racing heart
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A flutter in the chest or an abnormal heart rhythm
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Bowel or bladder incontinence, resulting in staining your underwear
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Section 9 IDP
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A decrease in movement speed
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Difficulty initiating movement
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Stiffness in your muscles (not joints)
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A stooped posture when walking
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Cramping of your hand when writing
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Section 10 DP
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Abnormal body movements (such as twitching legs)
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Desires to flinch, clear your throat, or perform some type of movement
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Constant nervousness and a restless mind
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Compulsive behaviors
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Increased tightness and tone in specific muscles
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Section 11 CB
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Difficulty with balance, or balance that is noticeably worse on one side
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A need to hold the handrail or watch each step carefully when going down stairs
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Episodes of dizziness
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Nausea, car sickness, or seasickness
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A quick impact after consuming alcohol
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A slight hand shake when reaching for something
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Back muscles that tire quickly when standing or walking
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Chronic neck or back muscle tightness.
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Section 12 BCC
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Low brain endurance for focus and concentration
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Cold hands and feet
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Must exercise or drink coffee to improve brain function
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Poor nail health
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Fungal growth on toenails
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Must wear socks at night
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Nail beds are white instead of pink
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The tip of the nose is cold
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Section 13 SM
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Irritable, nervous, or light-headed between meals
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Feeling energized after meals
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Difficulty eating large meals in the morning
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Energy level drops in the afternoon
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Crave sugar and sweets in the afternoon
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Wake up in the middle of the night
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Difficulty concentrating before eating
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Depend on coffee to keep going
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Section 14 PUS
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Fatigue after meals
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Sugar and sweet cravings after meals
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Difficulty losing weight
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Increased frequency of urination
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Difficulty falling asleep
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Increased appetite
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Section 15 SBF
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Always have projects and things that need to be done
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Never have time for yourself
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Not getting enough sleep or rest
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Difficulty getting regular exercise
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Feel that you are not accomplishing your life's purpose
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Section 16 EFA
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Dry and unhealthy skin
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Dandruff or a flaky scalp
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Consumption of processed foods that are bagged or boxed
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Consumption of fried foods
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Difficulty consuming raw nuts or seeds
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Difficulty consuming fish (not fried)
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Difficulty consuming olive oil, avocados, flax seed oil, or natural fats
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Section 17 BGA
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Difficulty digesting food
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Constipation or inconsistent bowel movements
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Increased bloating or gas
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Abdominal distention after meals
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Difficulty digesting protein-rich foods
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Difficulty digesting starch-rich foods
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Difficulty digesting supplements or large bites of food
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Abnormal gag reflex
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Section 18 BIA
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Brain fog (unclear thoughts or concentration)
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Pain and Inflammation
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Noticeable variation in mental speed
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Brain fatigue after meals
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Brain fatigue after exposure to chemicals, scents, or pollutants
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Brain fatigue when the body is inflamed
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Section 19 GI
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Grain consumption leads to tiredness
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Grain consumption makes it difficult to focus and concentrate
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Feel better when bread and grains are avoided
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Grain consumption causes the development of any symptoms
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A 100% gluten-free diet
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Section 20 IB
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A diagnosis of celiac disease, gluten sensitivity, hypothyroidism
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Family members who have been diagnosed with an autoimmune disease
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Family members who have been diagnosed with celiac disease or gluten sensitivity
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Changes in brain function with stress, poor sleep, or immune activation
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Section 21 SC
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A loss of pleasure in hobbies and interests
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Feeling overwhelmed with ideas to manage
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Feelings of inner rage or unprovoked anger
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Feelings of paranoia
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Feelings of sadness for no reason
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A loss of enjoyment in life
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A lack of artistic appreciation
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Feelings of sadness in overcast weather
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A loss of enjoyment in favorite foods
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A loss of enjoyment in friendships and relationships
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Inability to fall into deep, restful sleep
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Feelings of dependency on others
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Feelings of susceptibility to pain
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Section 22 DC
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Feelings of worthlessness
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Feelings of hopelessness
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Self-destructive thoughts
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Inability to handle stress
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Anger and aggression while under stress
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Feelings of tiredness, even after many hours of sleep
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A desire to isolate yourself from others
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An unexplained lack of concern for family and friends
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An inability to finish tasks
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Feelings of anger for minor reasons
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Section 23 ACH
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A decrease in visual memory (shapes and images)
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A decrease in verbal memory
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Occurrences of memory lapses
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A decrease in creativity
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A decrease in comprehension
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Difficulty calculating numbers
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Difficulty recognizing objects and faces
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A change in opinion about yourself
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Slow mental recal
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Section 24 CAT
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A decrease in mental alertness
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A decrease in mental speed
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A decrease in concentration quality
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Slow cognitive processing
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Impaired mental performance
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An increase in the ability to be distracted
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Need coffee or caffeine sources to improve mental function
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Section 25 GC
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Feelings of nervousness or panic for no reason
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Feelings of dread
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Feelings of a "knot" in your stomach
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Feelings of being overwhelmed for no reason
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Feelings of guilt about everyday decisions
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A restless mind
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An inability to turn off the mind when relaxing
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Disorganized attention
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Worry over things never thought about before
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Feelings of inner tension and inner excitability
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Are there any other concerns or interests you have about your health that you would like us to address?
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Doctor's notes (leave blank for doctor to fill)
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|
