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

Please Enter The Code Below
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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

Please Enter The Code Below
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