Chicago Dizziness & Hearing

https://www.dizzy-doc.com

New patient intake questionnaire

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Introduction

Please schedule an appointment before completing this questionnaire! If you have not yet scheduled an appointment, then please call us (312‑274‑0197) or email us (reception@dizzy-doc.com) to do so.

After you have scheduled an appointment, please complete this intake questionnaire carefully. On average, patients spend about 45 to 50 minutes filling it out. We realize that it requires substantial effort. However, your completing this questionnaire enables us to spend more time during your clinic visit examining you, which will help us in your diagnosis and treatment.

While going through the questionnaire, items colored in orange are ones that you must complete in order to proceed. These required items will turn green after you answer them.

Please answer the questions accurately and truthfully. Providing inaccurate or untruthful answers will limit appropriate evaluation.


Technical notes

This web-based questionnaire is compatible with the desktop-based browsers Chrome® (version 37 and above), Firefox® (version 23 and above), and Opera® (version 22 and above).

This questionnaire is not compatible with the browsers Internet Explorer® or Safari®.

Whichever browser you use, make sure that it is JavaScript enabled (which is the default on most browsers) and that autofill is disabled.

You must be connected to the Internet (“online”) in order for this questionnaire to work properly. If you are offline, it will be unable to send your responses to Chicago Dizziness & Hearing.

As long as you use this intake questionnaire on the web site to which Chicago Dizziness & Hearing directs you, it is guaranteed to be free of viruses and other malware.

In this questionnaire we will not ask you for your social security number, or personal financial information.

If you are unable or unwilling to do this questionnaire online, then you may download a printable version here.

If you wish to have a copy of your responses for your own records, then you can print each page (either to a printer, or to save as a PDF file) as you work through the questionnaire.



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Security question

Select a security question and answer

In case you pause during the questionnaire and come back later to complete it, your personal information should be protected. For this reason, please choose a security question and its answer.


Choose your security question: 
Enter the answer to the question: 
Enter the answer again (must match): 

Verify identity

Please enter the following information to verify your identity
First name: 
Last name: 
Date of birth: 
Please answer the security question, “

Who is filling out this questionnaire?

Is the patient filling out this questionnaire?

Who is helping the patient with this questionnaire, or filling it out on behalf of the patient?

Relationship to patient

Patient demographics

 Should be full legal name, for example, “Michael” rather than “Mike”

Health insurance information

Do you plan to have your visit at Chicago Dizziness and Hearing be covered by insurance or do you intend to be self-pay?

Type of insurance Please select the type of health insurance plan you have.


Please enter the policy number or ID number of the insurance plan:

Please enter the group number of the insurance plan

Please enter the name of the person who is the primary subscriber to the insurance plan

Please enter the date of birth of the subscriber

Please select the relationship of the subscriber to the patient

Referring physician

Were you referred to Chicago Dizziness & Hearing by a physician?

Is the referring physician's address in the United States?


Primary care physician

Do you have a primary care physician, such as an internist, general practitioner or pediatrician?

Is the primary care physician's address in the United States?


Other addressees

If you would like Chicago Dizziness & Hearing to send a copy of the letter about your visit to anybody else, such as other subspecialty physicians, physical therapists or other healthcare providers, then please enter their names and complete addresses below. Otherwise, simply leave it blank.

Type of consultation

The main purpose of my visit to Chicago Dizziness & Hearing is (choose only one):

Download PDF of questionnaire

Please click the button below to download a PDF of the questionnaire


Once you have downloaded the PDF of the questionnaire, please print it, fill it out on paper, and either fax it to us (312-376-8707) or mail it to us (at Chicago Dizziness and Hearing, 645 North Michigan Avenue, Suite 410, Chicago, IL 60611-5800).

Present illness

I am here primarily because of (check all that apply):

Brief summary of the reason for your visit

In just a few sentences, please summarize why you are coming to Chicago Dizziness & Hearing (maximum 3000 characters).


Characters remaining: 3000

Disequilibrium

Even if disequilibrium is not your main symptom, do you suffer from any disequilibrium at all?

What does the disequilibrium feel like?

Please characterize the disequilibrium (scroll down to see all the options, and check all that apply):

What makes the disequilibrium worse?

What factors make the disequilibrium worse? (scroll down to see all the options, and check all that apply)

What sorts of treatments have you tried for the disequilibrium?

What treatments have you tried for the disequilibrium?
Did the physical therapy help?

Did the acupuncture help?

Did the acupuncture help?

Tell us about the other therapies Other therapies tried:


Time pattern of the disequilibrium

Tell us about the first and last times the disequilibrium occurred
When did the disequilibrium first begin? Or when was the first time that the disequilibrium ever occurred?
The disequilibrium first started on

When did the disequilibrium last end? Or when was the last time that the disequilibrium ever occurred?
The disequilibrium last ended on

Tell us about whether the disequilibrium is intermittent or constant
Is the disequilibrium intermittent or constant?

Tell us about the duration of the episodes of disequilibrium
Adjust the sliders below to indicate how long the episodes of disequilibrium are.

Very short Very long

Very short Very long

Tell us about the frequency of the episodes of disequilibrium
Adjust the sliders below to indicate how often the episodes of disequilibrium occur.

Very often Very rare

Very often Very rare

Other features of the disequlibrium

How intense is the disequilibrium? (check all that apply)

Do you ever get any warning that disequilibrium is about to happen?

Has the disequilibrium caused any falls in the past 12 months?

Has the disequilibrium limited your driving?

Does the disequilibrium feel better when you are in a moving car? (That’s right, does the dizziness feel better when you’re in a car.)

Dizziness impact inventory

Dizziness impact inventory The purpose of this inventory is to identify difficulties that you may be experiencing because of your disequilibrium. Please answer "yes," "no" or "sometimes" to each question. Answer each question as it pertains to your disequilibrium problem only. Scroll down to see all the questions.


Additional comments about disequilibrium

If you have anything else you would like us to know about the disequilibrium, please enter it below (maximum 3000 characters).


Characters remaining: 3000

Ear symptoms

Even if ear problems are not your main symptom, do you suffer from any ear symptoms at all?

Ear symptoms

Please tell us about your ear symptoms and when they began. Scroll down to see all the choices.
Left ear symptoms
This began
This began
This began
This began
This began
This began

Right ear symptoms
This began
This began
This began
This began
This began
This began

Things that trigger or exacerbate the ear symptoms

Please tell us about the things that trigger or worsen the ear symptoms. Scroll down to see all the options.

Things that improve the ear symptoms

Tell us whether anything improves the ear symptoms. Scroll down to see all the options.

Time pattern of the ear symptoms

Tell us about the first and last times the ear symptoms occurred
When did the ear symptoms first begin? Or when was the first time that any of the the ear symptoms ever occurred?
The ear symptoms first started on

When did the ear symptoms last end? Or when was the last time that any of the ear symptoms ever occurred?
The ear symptoms last ended on

Tell us about whether the ear symptoms are intermittent or constant
Are the ear symptoms intermittent or constant?

Tell us about the duration of the episodes of ear symptoms
Adjust the sliders below to indicate how long the episodes of ear symptoms are.

Very short Very long

Very short Very long

Tell us about the frequency of the episodes of ear symptoms
Adjust the sliders below to indicate how often the episodes of ear symptoms occur.

Very often Very rare

Very often Very rare

Other features of the tinnitus

Have you tried using masking strategies for the tinnitus? (Masking is when you add extra sounds to your environment, such as a fan or the radio, in order to make your tinnitus seem softer.)

Does the tinnitus interfere with your sleep?

Does the tinnitus interfere with your concentration?

Does the tinnitus make you feel depressed?

Tinnitus impact inventory

Tinnitus impact inventory The purpose of this inventory is to identify difficulties that you may be experiencing because of your tinnitus. Please answer "yes," "no" or "sometimes" to each question. Answer each question as it pertains to your tinnitus problem only. Scroll down to see all the questions.


Additional comments about the ear symptoms

If you have anything else you would like us to know about the ear symptoms, please enter it below (maximum 3000 characters).


Characters remaining: 3000

Headache

Even if headache is not your main symptom, do you suffer from any headaches at all that you consider more than minor or trivial?

Single or multiple types of headaches

Do you have just one type of headache, or multiple kinds of headaches?

Location of headache

Please indicate which area(s) are affected by the most bothersome type of headache that you get. Hover your cursor over any area, and click to select it. You must choose one or more locations.
Head, three views

Features of the headache

Please answer the following questions with respect to the most bothersome type of headache that you get. Scroll down to see all the options.

What is the range of intensity of the most bothersome type of headache? (check all that apply)

What is the quality of the most bothersome type of headache? (check only one)

Immediately before, or during, or shortly after the headache, I also experience the following associated symptoms (check all that apply):

The following things tend to make the headache worse (check all that apply):

The following things sometimes trigger the headache (check all that apply):

Does the headache sometimes occur at a specific period of time interval with respect to your menstrual cycle?

The following things tend to make the headache better (check all that apply):


Time pattern of the headache

Tell us about the first and last times the headache occurred
When did the headache first begin? Or when was the first time that the headache ever occurred?
The headache first started on

When did the headache last end? Or when was the last time that the headache ever occurred?
The headache last ended on

Tell us about whether the headache is intermittent or constant
Is the headache intermittent or constant?

Tell us about the duration of the headaches
Adjust the sliders below to indicate how long headaches are.

Very short Very long

Very short Very long

Tell us about the frequency of the headaches
Adjust the sliders below to indicate how often the headaches.

Very often Very rare

Very often Very rare

Headache impact inventory

Work and school
Question 1: How many days of work or school did you completely miss in the last 3 months due to your headaches? } Sum should be no greater than 90 days
Zero days Ninety days
Question 2: How many days in the last 3 months was your productivity at work or school reduced by half or more due to your headaches? (Do not include days you counted in question 1 where you missed work or school completely.)
Zero days Ninety days
Household work
Question 3: On how many days in the last 3 months did you not do household work because of your headaches? } Sum should be no greater than 90 days
Zero days Ninety days
Question 4: How many days in the last 3 months was your productivity in household work reduced by half or more due to your headaches? (Do not include days you counted in question 3 where you did not do household work at all.)
Zero days Ninety days
Family, social and leisure activities
Question 5: On how many days in the last 3 months did you completely miss family, social or leisure activities because of your headaches?
Zero days Ninety days



Headache impact
Question 6: When you have headaches, how often is the pain severe?
Question 7: How often do headaches limit your ability to do usual daily activities including household work, work, school, or social activities?
Question 8: When you have a headache, how often do you wish you could lie down?
Question 9: In the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches?
Question 10: In the past 4 weeks, how often have you felt fed up or irritated because of your headaches?
Question 11: In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities?

Headache impact inventory

School attendance and functioning
Question 1: In the past 3 months, on how many full days of school were missed due to your headaches? 0 days } Sum should be no greater than 90 days
Zero days Ninety days
Question 2: In the past 3 months, on how many partial days of school were missed due to your headaches? (Do not include days you counted in question 1 where you missed full days of school.) 0 days
Zero days Ninety days
Question 3: In the past 3 months, on how many days did you function at less than half your ability in school because of your headaches? (Do not include days you counted in questions 1 and 2.) 0 days
Zero days Ninety days
Activities at home
Question 4: In the past 3 months, on how many days were you not able to do things at home at all due to your headaches (i.e., chores, homework, etc.)? 0 days
Zero days Ninety days
Other activities outside of school
Question 5: In the past 3 months, on how many days did you not participate at all in other activities due to your headaches (i.e., play, go out, sports, etc.)? 0 days } Sum should be no greater than 90 days
Zero days Ninety days
Question 6: In the past 3 months, on how many days did you participate in these activities, but functioned at less than half your ability due to your headaches? (Do not include days you counted in question 5 when you did not do these activities at all.) 0 days
Zero days Ninety days


Additional comments about headaches

If you have anything else you would like us to know about the headaches, please enter it below (maximum 3000 characters).


Characters remaining: 3000

Comments about other symptoms

If you have other symptoms, please describe them below (maximum 3000 characters).


Characters remaining: 3000

Allergic problems

Do you suffer from any allergic symptoms that are more than simply mild?

Please indicate your allergic symptoms (check all that apply):

Do any of your biological relatives also suffer from allergy symptoms? (check all that apply)

At approximately what age did your allergic symptoms begin?

Over the course of a typical year, how long (in total) are the allergic symptoms usually present?

Do you have any common environmental triggers for your allergies? (check all that apply)

Do you have any other triggers for your allergies? (check all that apply)

Have you had allergy testing done before for any of the following? (check all that apply)

What type of allergy testing did you have done? (check all that apply)

Do you already know that you are definitely allergic to any of the following? (check all that apply)

Have you ever had asthma?

What is (or was) the severity of your asthma?

Are you interested in being tested for allergies to pollens, mold and animal danders?

Have any of the following ever caused you to have anaphylaxis or any other severe allergic reactions? (check all that apply)