Chicago Dizziness & Hearing 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.

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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.

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In order to proceed with the questionnaire, please check here to indicate you understand and accept that, unless mandated by state or federal law, Chicago Dizziness and Hearing does not do paperwork related to worker’s compensation, disability, functional capacity evaluations, etc., nor do we respond to attorney queries.

In order to proceed with the questionnaire, please check here to indicate you understand and accept that you and anyone who accompanies you to clinic will abide by clinic policies pertaining to correctly wearing an appropriate mask during the time of COVID19.

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Security question

Select a security question and answer

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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?

Yes, I am the patient, and I am the one filling out this questionnaire.
No, I am not the patient, but I am helping the patient fill out this questionnaire.

Patient demographics

Salutation:
Patient's first name:		Should be full legal name, for example, “Michael” rather than “Mike”
Patient's middle name:
Patient's last name:
Patient's date of birth:		We accept patients between the ages of 18 and 105 years
Patient's legal gender:
Patient's handedness:
Patient's street address:
Patient's city:
Patient's state:
Patient's zip code:
Type of residence:
Patient's phone number:
Patient's email:
Verify patient's email:
Date of appointment:
Appointment is with this practitioner:
Have you ever been seen in our office before?

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? I plan for the cost of my visit to be covered by my health insurance plan. I intend to self-pay my visit (without coverage from health insurance).

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

Please type in the complete name of your insurance plan here:

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? Yes, I was referred by a physician. No, I was not referred by a physician.

Is the referring physician's address in the United States? Yes, the referring physician's address is inside the United States. No, the referring physician's address is outside the United States.

Referring physician's first name:
Referring physician's last name:
Street address, line 1:
Street address, line 2:
Referring physician's city:
Referring physician's state:
Referring physician's zip code:
Referring physician's phone number:

Referring physician's first name:
Referring physician's last name:
Referring physician's address:

Primary care physician

Do you have a primary care physician, such as an internist, general practitioner or pediatrician? Yes, I do have a primary care physician. No, I do not have a primary care physician.

Is the primary care physician's address in the United States? Yes, the primary care physician's address is inside the United States. No, the primary care physician's address is outside the United States.

Primary care physician's first name:
Primary care physician's last name:
Street address, line 1:
Street address, line 2:
Primary care physician's city:
Primary care physician's state:
Primary care physician's zip code:
Primary care physician's phone number:

Primary care physician's first name:
Primary care physician's last name:
Primary care physician's address:

Type of consultation

The main purpose of my visit to Chicago Dizziness & Hearing is (choose only one): For evaluation and treatment. For a second opinion. For a worker's compensation case. For an Independent Medical Examination (“IME”) — this when a patient is sent to our office by an attorney, insurance company or employer to be examined by a physician.

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): Dizziness, imbalance, lightheadedness, or other forms of disequilibrium. Hearing problems, such as hearing loss, excessively sensitive hearing, or sound distortion. Abnormal sounds in the ear, also called “tinnitus.” Other ear problems, such as ear fullness, ear wax, blood or other fluid coming out of the ear. Headache or facial pain. Other.

What does the disequilibrium feel like?

What makes the disequilibrium worse?

What factors make the disequilibrium worse? (scroll down to see all the options, and check all that apply) There are no specific exacerbators of the dizziness. Rolling over in bed towards the left. Rolling over in bed to right. Bending forward. Standing up. Rapid head movements. Other changes in position of the head, neck or body. Walking in the dark. Walking through very narrow spaces (such as hallways or grocery store aisles). Walking through very wide open spaces. Television or computer screens. Movies (in a movie theater). Heights. Going over bridges (while driving or walking). Going through tunnels (while driving or walking). Elevators. Underwater diving. Sneezing, coughing, straining at stool. Traveling by car. Traveling by airplane. Traveling by boat. Loud noises. Bright lights. Alcohol. Caffeine. Certain foods. Certain smells. Heat (such as hot showers or hot weather). A specific time of day, a specific time of year, or a specific season. Stress. Menses (if relevant).

Other.

What sorts of treatments have you tried for the disequilibrium?

What treatments have you tried for the disequilibrium? Medications.

Tell us about the medications Medications that helped the disequilibrium:
Medications that did not help the disequilibrium:

Physical therapy.

Did the physical therapy help? Physical therapy helped. Physical therapy did not help.

Acupuncture.

Did the acupuncture help? Acupuncture helped. Acupuncture did not help.

Chiropractic manipulation.

Did the acupuncture help? Chiropractic manipulation helped. Chiropractic manipulation did not help.

Other therapies.

Tell us about the other therapies Other therapies tried: These other therapies helped. These other therapies did not help.

Actually, I have not tried any treatments at all for the disequilibrium.

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? The disequilibrium is intermittent. It occurs in episodes. The disequilibrium is constant. It is there every single waking moment, and never stops.

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

On average, the shortest duration is (Please select).

Very short

Very long

On average, the longest duration is (Please select).

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.

The most frequent that the episodes of disequilibrium occur is once every (Please select).

Very often

Very rare

The least frequent that the episodes of disequilibrium occur is once every (Please select).

Very often

Very rare

Other features of the disequlibrium

How intense is the disequilibrium? (check all that apply) Mild. Moderate. Severe.

Do you ever get any warning that disequilibrium is about to happen? There is never any warning. There is sometimes a warning. There is always a warning.

Describe the warning:

Has the disequilibrium caused any falls in the past 12 months? The disequilibrium has not caused any falls in the past 12 months. The disequilibrium has caused falls in the past 12 months.

How many times has the disequilibrium caused you to fall in the past 12 months?

Has the disequilibrium limited your driving? The disequilibrium has not limited my driving at all. The disequilibrium has limited my driving somewhat but I continue to drive. The disequilibrium has completely prevented me from driving. I don’t drive anyway, even when I’m not suffering from disequilibrium.

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.) The disequilibrium feels worse when I’m in a moving car. The disequilibrium does not seem to change when I’m in a moving car. Yes, the disequilibrium actually does feel better when I’m in a moving car. I never get in a moving car, so I don’t know whether it affects the disequilibrium.

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.

Does looking upwards increase your disequilibrium?
Because of your disequilibrium, do you feel frustrated?
Because of your disequilibrium, do you restrict your travel for work, school or recreation?
Does walking down the aisle of a supermarket increase your disequilibrium?
Because of your disequilibrium, do you have difficulty getting into or out of bed?
Does your disequilibrium significantly restrict your participation in social activities such as going out to dinner, going to movies, to dancing, or to parties?
Because of your disequilibrium, do you have difficulty reading?
Does performing more ambitious activities, like sports, dancing, household chores such as sweeping or putting dishes away increase your disequilibrium?
Because of your disequilibrium are you afraid to leave your home without having someone accompany you?
Because of your disequilibrium, have you felt embarrassed in front of other people?
Do quick movements of your head increase the disequilibrium?
Because of your disequilibrium, do you avoid heights?
Does turning over in bed increase the disequilibrium?
Because of your disequilibrium, is it difficult for you to do strenuous housework, yardwork, or other chores?
Because of your disequilibrium, are you afraid people may think you are intoxicated?
Because of your disequilibrium, is it difficult for you to walk by yourself?
Does walking down a sidewalk increase your disequilibrium?
Because of your disequilibrium, is it difficult for you to concentrate?
Because of your disequilibrium, is it difficult for you to walk around your house in the dark?
Because of your disequilibrium, are you afraid to stay at home alone?
Because of your disequilibrium, do you feel handicapped?
Has your disequilibrium placed stress on your relationships with members of your family or friends?
Because of your disequilibrium, do you feel depressed?
Does your disequilibrium interfere with your job, household responsibilities or school work?
Does bending over increase your disequilibrium?

Ear symptoms

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

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.

Nothing triggers or worsens the ear symptoms.
Jaw movements.
Neck movements.
Yawning.
Coughing, sneezing, straining.
Airplane travel.
Being in a quiet environment.
Loud noises.
Being in an environment with many different noises (such as a dinner party).
Fatigue or sleep deprivation.
Salt.
Alcohol.
Caffeine.

Certain foods.

Stress or anxiety.

Medications.

Other.

Things that improve the ear symptoms

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

Hearing aids.
Ear plugs.
Being in a quiet environment.
Masking (adding various types of sound in your environment, such as music, a fan, or radio static).
Rest.

Medications.

Other.

Actually, I have not tried any treatments at all for the ear symptoms.

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? The ear symptoms are intermittent. It occurs in episodes. The ear symptoms are constant. It is there every single waking moment, and never stops.

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.

On average, the shortest duration is (Please select).

Very short

Very long

On average, the longest duration is (Please select).

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.

The most frequent that the episodes of ear symptoms occur is once every (Please select).

Very often

Very rare

The least frequent that the episodes of ear symptoms occur is once every (Please select).

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.) No, I have not tried masking. Yes, I have tried masking.

Please list the masking you have tried:

Does the tinnitus interfere with your sleep? No, the tinnitus does not interfere with my sleep. Yes, the tinnitus does interfere with my sleep.

Does the tinnitus interfere with your concentration? No, the tinnitus does not interfere with my concentration. Yes, the tinnitus does interfere with my concentration.

Does the tinnitus make you feel depressed? No, the tinnitus does not make me feel depressed. Yes, the tinnitus does make me 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.

Because of your tinnitus is it difficult to concentrate?
Does the loudness of your tinnitus make it difficult for you to hear people?
Does your tinnitus make you angry?
Does your tinnitus make you feel confused?
Because of your tinnitus do you feel desperate?
Do you complain a great deal about your tinnitus?
Because of your tinnitus do you have trouble falling asleep at night?
Do you feel you cannot escape your tinnitus?
Does your tinnitus interfere with your ability to enjoy social activities (such as going out to a restaurant or to the movies)?
Because of your tinnitus do you feel frustrated?
Because of your tinnitus do you feel that you have a terrible disease?
Does your tinnitus make it difficult for you to enjoy life?
Does your tinnitus interfere with your job, school or household responsibilities?
Because of your tinnitus do you find that you are often irritable?
Because of your tinnitus is it difficult for you to read?
Does your tinnitus make you upset?
Do you feel that your tinnitus problem has placed stress on your relationship with members of your family and friends?
Do you find it difficult to focus your attention away from your tinnitus and on other things?
Do you feel that you have no control over your tinnitus?
Because of your tinnitus do you often feel tired?
Because of your tinnitus do you feel depressed?
Does your tinnitus make you feel anxious?
Do you feel that you can no longer cope with your tinnitus?
Does your tinnitus get worse when you are under stress?
Does your tinnitus make you feel insecure?

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? Yes, I at least sometimes experience headaches that are more than just minor or trivial. No, I never experience any headaches at all that are more than just minor or trivial.

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.

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)

Mild.
Moderate.
Severe.

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

Sharp.
Dull.
Pressure.
Throbbing.

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

Blurry vision.
Double vision.
Wavy lines in my vision.
Bright spots in my vision.
Dark spots in my vision.
Dizziness.
Numbness or tingling.
Nausea.
Vomiting.
Sensitivity to light.
Sensitivity to sound.

Sensitivity to smells.

Other.

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

Physical exertion.
Movement.

Other.

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

Barometric pressure changes, or other weather changes.
Sleep deprivation.
Dehydration.

Other.

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

Yes.
No.

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

Lying in a dark, quiet room.
Sleep.

Medication(s).

Other.

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? The headache is intermittent. It occurs in episodes. The headache is constant. It is there every single waking moment, and never stops.

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

On average, the shortest duration is (Please select).

Very short

Very long

On average, the longest duration is (Please select).

Very short

Very long

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

The most frequent that the headaches occur is once every (Please select).

Very often

Very rare

The least frequent that the headaches occur is once every (Please select).

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?		0 days	}	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.)		0 days
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?		0 days	}	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.)		0 days
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?		0 days
Zero days	Ninety days

Total number of days missed: 0

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

Total number of days missed: 0

Allergic problems

Do you suffer from any allergic symptoms that are more than simply mild? No, I do not suffer from any allergic symptoms. Yes, I do suffer from allergic symptoms.

Spinning.	Tumbling.
Cart-wheeling.	Rocking.
Light-headedness.	Nausea.
Vomiting.	Double vision.
Blurred vision.	Jumpy vision.
Headache.

Left-sided ear pain.	This began
Left-sided noise sensitivity.	This began
Left-sided ear fullness.	This began
Left-sided hearing loss.	This began
Left-sided use of hearing aid.	This began
Left-sided tinnitus (extra sounds in the ear). Ringing. Hissing. Buzzing. Music. Voices. Locusts. Crickets. Thumping. Other.	This began

Right-sided ear pain.	This began
Right-sided noise sensitivity.	This began
Right-sided ear fullness.	This began
Right-sided hearing loss.	This began
Right-sided use of hearing aid.	This began
Right-sided tinnitus (extra sounds in the ear). Ringing. Hissing. Buzzing. Music. Voices. Locusts. Crickets. Thumping. Other.	This began

PLEASE READ THIS PAGE

Please use the desktop-based browsers Chrome®, Firefox®, or Opera®.

Please do not use the browsers Safari® or Internet Explorer®.

Please do not use a cell phone or tablet for completing this questionnaire.

Introduction

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Retrieve previously stored questionnaire?

Security question

Verify identity

Who is filling out this questionnaire?

Patient demographics

Health insurance information

Referring physician

Primary care physician

Other addressees

Type of consultation

Download PDF of questionnaire

Present illness

Brief summary of the reason for your visit

Disequilibrium

What does the disequilibrium feel like?

What makes the disequilibrium worse?

What sorts of treatments have you tried for the disequilibrium?

Time pattern of the disequilibrium

Other features of the disequlibrium

Dizziness impact inventory

Additional comments about disequilibrium

Ear symptoms

Ear symptoms

Things that trigger or exacerbate the ear symptoms

Things that improve the ear symptoms

Time pattern of the ear symptoms

Other features of the tinnitus

Tinnitus impact inventory

Additional comments about the ear symptoms

Headache

Single or multiple types of headaches

Location of headache

Features of the headache

Time pattern of the headache

Headache impact inventory

Headache impact inventory

Additional comments about headaches

Comments about other symptoms

Allergic problems