Dizziness In Orthopaedic Physical Therapy Practice: History And Physical Examination Page 3
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30Table 1. Patient self-report intake questionnaire.
PATIENT INTAKE QUESTIONNAIRE
Patient Name_________________________________________ Age__________ Gender M / F
MEDICAL HISTORY
Have you in the past been diagnosed with or currently have (check all that apply):
Recent viral infection
Recent viral infection
Head trauma
Head trauma
Recent inoculation
Recent inoculation
Neck trauma
Neck trauma
Multiple sclerosis
Multiple sclerosis
Inner or middle ear infection
Inner or middle ear infection
Lung cancer
Lung cancer
Middle ear surgery
Middle ear surgery
Ovarian cancer
Ovarian cancer
Inner ear degeneration
Inner ear degeneration
Hodgkin’s disease (lymphatic cancer)
Hodgkin’s disease (lymphatic cancer)
Recent upper respiratory infection
Recent upper respiratory infection
Breast cancer
Breast cancer
Recent bacterial infection
Recent bacterial infection
Heart disease
Heart disease
Syphilis
Syphilis
Chronic obstructive lung disease
Chronic obstructive lung disease
Tuberculosis
Tuberculosis
Atherosclerosis (hardening arteries)
Atherosclerosis (hardening arteries)
Rheumatoid arthritis
Rheumatoid arthritis
Thromboembolic disease (blood clots)
Thromboembolic disease (blood clots)
Crohn’s disease
Crohn’s disease
Neck degeneration
Neck degeneration
Polyarteritis (auto-immune disease
Polyarteritis (auto-immune disease
Recurrent episodes of vertebrobasilar ischaemia
Recurrent episodes of vertebrobasilar ischaemia
affecting the arteries)
(limited blood supply to the brain)
AIDS
AIDS
Visual impairments
Visual impairments
Recent chicken pox
Recent chicken pox
Migraine or migraine-related disorders
Migraine or migraine-related disorders
Recent mumps
Recent mumps
Joint replacement in the leg
Joint replacement in the leg
Recent poliomyelitis
Recent poliomyelitis
Other orthopaedic surgical procedure
Other orthopaedic surgical procedure
Mononucleosis (Epstein-Barr, Mono)
Mononucleosis (Epstein-Barr, Mono)
Have you recently:
Been in contact with rodents (mice, guinea
Been in contact with rodents (mice, guinea
Gone fl ying
Gone fl ying
pigs, hamsters)
Coughed, sneezed, or strained forcefully
Coughed, sneezed, or strained forcefully
Gone diving
Gone diving
Lifted very heavy items
Lifted very heavy items
Has a member of your family ever been diagnosed with or currently have (check all that apply):
Coronary artery disease
Coronary artery disease
Familial paroxysmal ataxia
Familial paroxysmal ataxia
Peripheral vascular disease
Peripheral vascular disease
Meniere’s disease
Meniere’s disease
Spinocerebellar ataxia
Spinocerebellar ataxia
Otosclerosis
Otosclerosis
Friedreich’s ataxia
Friedreich’s ataxia
Migraine
Migraine
Ataxia-telangiectasia
Ataxia-telangiectasia
Vertebrobasilar migraine
Vertebrobasilar migraine
Have you used or are you currently using (check all that apply):
Gentamicin
Gentamicin
Phenytoin
Phenytoin
Alcohol
Alcohol
Heroin
Heroin
Potassium
Potassium
Amikacin
Amikacin
Isoniazid
Isoniazid
Procainamide
Procainamide
Angel Dust
Angel Dust
Kanamycin
Kanamycin
Propranolol
Propranolol
Antidepressants
Antidepressants
Levodopa
Levodopa
Pyridoxine
Pyridoxine
Antihypertensives
Antihypertensives
Meprobamate
Meprobamate
Quinidine
Quinidine
Aspirin
Aspirin
Methaqualone
Methaqualone
Quinine
Quinine
Barbiturates
Barbiturates
Methyldopa
Methyldopa
Reserpine
Reserpine
Benzodiazepines
Benzodiazepines
Metoclopramide
Metoclopramide
Streptomycin
Streptomycin
Bromocriptine
Bromocriptine
Monoamine oxidase
Monoamine oxidase
Taxol
Taxol
Butyrophenones
Butyrophenones
(MOA) inhibitors
Tetrabenazine
Tetrabenazine
Cis-platinum
Nitroglycerin
Nitroglycerin
Tobramycin
Tobramycin
Digitalis
Digitalis
Phencyclidine
Phencyclidine
Tricyclic antidepressants
Tricyclic antidepressants
Diuretics
Diuretics
Phenothiazines
Phenothiazines
Ethchlorvynol
Ethchlorvynol
How many different medications are you using in total on a daily basis? ____________
Are you taking the medication as prescribed? Y / N
224 / The Journal of Manual & Manipulative Therapy, 2005
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