Dizziness In Orthopaedic Physical Therapy Practice: History And Physical Examination Page 4
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30Table 2. History form (reason for referral indicated in green).
PATIENT HISTORY
Patient Name________________________________________________________ Date______________
Symptom description____________________________________________________________________
_______________________________________________________________________________________
Dysequilibrium
Dysequilibrium
Vertigo
Vertigo
Other dizziness
Presyncopal dizziness
Symptom onset
Sudden
Sudden
Insidious_______________________________________________________
Insidious_______________________________________________________
________________________________________________________________________
Precipitating factors
Constant
Intermittent
Intermittent
Episodic_______________________________________
Episodic_______________________________________
Episodic
_______________________________________________________________________________________
Transfer sitting to supine position
Transfer sitting to supine position
Prolonged standing
Rolling over in supine
Rolling over in supine
While recumbent and motionless
Head fl exion and extension
Head fl exion and extension
Wearing tight collar
Transfer supine to sitting position
Transfer supine to sitting position
Hyperventilation
Any head movement
Any head movement
Coughing
Caffeine
Urination
Exercise
Rapid rising from sitting
Alcohol
Prolonged neck extension-rotation
Emotional stimuli
Menstrual period
Pain
Pain
Arm activity
Fatigue
Anxiety
Fear
Prodromal symptoms Y/N Duration_________________________________________________________
Lightheadedness
Tachycardia
Pallor
Visual aura
Salivation
Other neurological aura
Blurred vision
Symptom latency Y/N Duration ____________________________________________________________
Symptom duration 30-60 sec______________________________________________________________
Symptom fatigability Y/N_________________________________________________________________
Associated symptoms
Ataxia_______________________________________________________________________________
Hearing
loss:
Sudden onset
Sudden onset
Fluctuating
Fluctuating
Progressive
Progressive
Left
Left
Right
Right
Both___________________
Both___________________
Tinnitus:
Tinnitus:
Left
Left
Right
Right
Both ___________________________________________________________
Both ___________________________________________________________
Sensation of fullness in the
ear:
Left
Left
Right
Right
Both_________________________________________
Both_________________________________________
Nausea______________________________________________________________________________
Nausea______________________________________________________________________________
Vomiting_____________________________________________________________________________
Dysarthria____________________________________________________________________________
Dizziness in Orthopaedic Physical Therapy Practice:
History and Physical Examination / 225
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