Questionnaire "Types of dizziness"

Date of investigation

Patient name

Age

Today residence

Accidents (Chornobyl, Three-Mile-Island, Spitak, Chechnia)

Gender

Height

Weight  

Weight changes

Profession

Professional hazards

General duration of disease

Allergy

Head trauma

Reason of disease

Intoxications  

Main diagnosis

Patient evaluation of dizziness intensity:

0.       Dizzy spells are absent,

1.        Low intensity everyday activities are easy going both professional and home,

2.        Half loweveryday activities are slightly disturbed,

3.        Middle - everyday activities are disturbed,

4.       Intensiveit is difficult to perform everyday activities,

5.        Very intensiveeveryday activities are impossible to be done.

Dizziness – distortion of perception of space, movement and time

Objective vertigo - sensation the subjects moving around the patient

Subjective vertigo – illusion of nonexistent movement, patient fill him moving

Imbalance (movement coordination disturbance) – sometimes is met alone. Patients are complaining of swaying, staggering, momentary push…

Orthostatics – discomfort sensations which appear after sudden standing up.

Kinetosis – a disorder caused by repetitive angular and linear acceleration and deceleration and characterized primarily by nausea and vomiting.

Acrophobia (height vertigo, height dizziness) – discomfort which appears at height.

Agoraphobia (supermarket syndrome) - (αγωρα – Grecian, market) discomfort in open, public places or crowds.

Nictophobia – discomfort, insureness in darkness and twilights.

Claustrophobia – discomfort appearing in small, closed spaces

Ascendophobia – discomfort while moving upstairs, patients note the necessity for visual control.

Descendophobia – discomfort during walking down the hill or descending the staircase, patients note the necessity of visual control.

Optokinesis – discomfort evoked by optokinetic stimuli, train or cars movement, sunrays blinking through the row of trees etc.

Nausea is identified as urge to vomit.

Vomiting – is forceful expulsion of gastric contents.

Headache as a substitute of dizziness

Black-out might appear during sudden movements of head, physical loadings or per se

Tinnitus as dizziness substitute

Numbness is unpleasant sensation of temporary loss of volunteer control of the parts of the body.

Headache regular – more often then once per month.

Patient evaluation of headache spell intensity:

0.       Headache spells are absent,

1.        Low intensity everyday activities are easy going both professional and home,

2.        Half loweveryday activities are slightly disturbed,

3.        Middle - everyday activities are disturbed,

4.       Intensiveit is difficult to perform everyday activities,

5.        Very intensiveeveryday activities are impossible to be done.

Headache unilateral.

Headache flickering.

Aura (headache precursor) visual

Scotoma - black spots

Photopsia - white spots

Teichopsia – white lines

Flickering

Aura acoustic – hearing phenomena as headache precursors

Aura somatosensory – numbness as headache precursor

Aura vestibular – giddiness or vertigo as headache precursor

Headache accompanied with nausea

Headache accompanied with vomiting episode, usually with some relief.

Phonophobia sounds become unpleasant during headache spell

Photophobia light become unpleasant during headache spell.

Osmophobia fragrances become unpleasant during headache spell.

Vertigo intensive vertigo during headache spell not resembling other types of vertigo, it is more close to giddiness or pseudovertigo.

Duration of headache spell

Meteosensitivity weather changes provoke headache attack or dizziness

Lunatismmoon cycles provoke headache attack or dizziness.

Magnetosensitivity magnetic storms, handy etc provoke headache attack or dizziness.

Pain in the heart area

Dispnoe attacks

Palpitations

Extrasystole, rhythm disturbances

ECG intervals: P

PQ

QRS

ST

Blood pressure: systolic

Diastolic

Pulse rate

Cholesterol

High density lipoproteins

Low density lipoproteins

Aterogenity index

Blood glucose

IgG HSV 1 immunoglobulin G to type 1 herpes

IgG HSV 2 immunoglobulin G to type 2 herpes

IgG HSV  immunoglobulin G to type rozeola herpes

IgG CMV  immunoglobulin G to cytomegalovirus

Heterofilic antibodies (IgG EBV)

Medication used

Thank you for cooperation


Copyright LITA Corp.                                                                     

 

Comments