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________________________________________________________________________
I. Do you experience any of the following sensations? Circle YES or NO to describe your feelings.
YES
NO
YES
YES
NO
NO
Feel like you are spinning in circles inside while the world stays
stationary?
Falling to one side? which side? ______________________________
Feel as though the world is spinning around you?
II. If you have dizziness, please circle YES or NO and fill in the spaces with additional information.
YES
YES
NO
NO
YES
YES
NO
NO
YES
YES
NO
NO
YES
NO
YES
NO
YES
YES
NO
NO
YES
NO
_____________________________________________________________________________________
3860 South Lindbergh Boulevard, #108 St. Louis, Missouri 63127
phone 314-729-0077
fax 314-729-0101 website www.soundhealthservices.com
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YES
NO
YES
YES
NO
NO
YES
YES
YES
NO
NO
NO
YES
NO
III. The following questions refer to other sensations you may have. Please circle YES or NO.
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
IV. Do you have any of the following symptoms related to your HEARING? Circle YES or NO.
YES
NO
YES
NO
YES
YES
NO
NO
YES
YES
NO
NO
V. Medical History Past and Present. Please circle all that affect you.
Constitutional : Weight loss (15 lbs or more)
Cardiovascular: Anemia
Fainting
Trouble sleeping
Heart Problems
High Cholesterol
Palpitations
Thyroid Disorder
Back pain
Treatment by psychiatrist/counselor
Neck Pain
Pneumonia
Sinusitis
Reflux
Irritable Bowel
Lazy Eye
Cataracts
Blurred Vision
Double Vision
Multiple Sclerosis
Deviated Septum
Macular Degeneration
Detached Retinas
Carpal Tunnel
Memory Loss
Seizures
Tremors
_____________________________________________________________________________________
3860 South Lindbergh Boulevard, #108 St. Louis, Missouri 63127
phone 314-729-0077
fax 314-729-0101 website www.soundhealthservices.com
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Streptomycin (antibiotic)
Furosemide (Lasix)
Gentamicin (antibiotic)
Tobramycin (antibiotic)
Kanamycin (antibiotic)
Vancomycin (antibiotic)
VII. The last section refers to your lifestyle and habits. Please answer to the best of your ability.
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
Please tell us anything else relevant to your health that we may not have asked you on this questionnaire.
_____________________________________________________________________________________
3860 South Lindbergh Boulevard, #108 St. Louis, Missouri 63127
phone 314-729-0077
fax 314-729-0101 website www.soundhealthservices.com
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