Vertigo Survey

Vertigo, Dizziness and Balance Screening Survey

Vertigo, dizziness and balance disorders are common problems that can severely impact a person’s lifestyle and confidence resulting in restricted physical and social functioning. People become afraid of falling and these disorders do increase the risks of falling. Vertigo and dizziness can be caused by a wide range of problems such as viral or bacterial infections of the ears, head trauma, falls or whiplash injuries, aging, hereditary, side-effects of some medications and complications of other medical conditions.

 This screening survey has been designed to assess the nature of your vertigo or dizziness and determine treatable elements of your vertigo, thus assisting you to develop a management plan. The screening survey will take 5 minutes to complete and your answers will be confidential. When you have completed the survey, please enter the code in the box and click send appointment request.

       SURVEY      

    All fields are required.

    First Name

    Surname

    Address

    Date of Birth

    Contact Phone Number

    Email Address

    Are You A New Client?
    YesNo

    Are You A Member of a Health Fund?
    YesNo

    Workers Compensation?
    YesNo

    Third Party Insurance?
    YesNo

    Have you had a recent illness?
    YesNo

    Did you have an illness prior to your last attack?
    YesNo

    Do you have a history of loss of consciousness or fainting?
    YesNo

    Do you have migraine headaches?
    YesNo

    Do you have recent changes in your hearing?YesNo

    Do you have neck pain or stiffness?
    YesNo

    Do you have allergies or sinus problems?
    YesNo

    Do you have an anxiety disorder?
    YesNo

    Do you have problems with your blood pressure?
    YesNo

    Do you have an irregular heartbeat?
    YesNo

    Do your jaw joints; click, grate, pop or make any noises while talking, chewing, eating or yawning?
    YesNo

    Did you fall, incur whiplash or have head trauma prior to your vertigo?
    YesNo

    Have you started any new medications recently?
    YesNo


    About your dizziness/vertigo, is it...

    Unsteady?
    YesNo

    Lightheaded?
    YesNo

    Twirling?
    YesNo

    Rolling?
    YesNo

    Rocking?
    YesNo

    Unbalanced?
    YesNo

    Unsure?
    YesNo

    Like a merry go round or rollercoaster?
    YesNo

    Unsure of your footing?
    YesNo

    Disorientated?
    YesNo

    Disconnected?
    YesNo

    Woozy?
    YesNo

    Swaying?
    YesNo

    Spinning?
    YesNo

    Wobbly?
    YesNo

    Faint?
    YesNo

    Whirling?
    YesNo

    If you answered ‘Yes’ to any of these questions it is important to discuss a vertigo assessment and management plan with your physiotherapist or doctor. If you experience any of the symptoms outlined in the second part of the screening tool, it is also important to speak to one of the   physiotherapists at Rathmines Physiotherapy and Sports Injury Centre or your doctor – as many of these symptoms can be treated, and in some cases cured.

    For further information please contact Rathmines Physiotherapy and Sports Injury Centre on 4975 -1622 or email reception@rathminesphysio.com.au.

      All fields are required.

      First Name

      Surname

      Address

      Date of Birth

      Contact Phone Number

      Email Address

      Appointment Date

      Appointment Time

      Alternative Date

      Alternative Time

      Are You A New Client?
      YesNo

      Are You A Member of a Health Fund?
      YesNo

      Workers Compensation?
      YesNo

      Third Party Insurance?
      YesNo

      Service Required

      Area of Concern / Body Part