Regain your balance and your life.

Pre-Balance Testing Paperwork

Thank you for choosing Chesapeake Otolaryngology. We are looking forward to taking care of you.

The forms in this packet will help us provide the best care of you. Please read and fill them out prior to your balance testing.

Your doctor has scheduled you for ‘Balance Testing’ to help further understand the cause of your dizziness.

• The test takes around 60 minutes to complete• During the test you will wear goggles on your head to allow our team to observe how your

eyes respond to specific movements of your head.• Parts of the test may make you dizzy. This is OK and will help us determine what causes it.• We do not require someone drive you home, but we generally recommend it as some people

will be more sensitive to the parts of the test that can make you dizzy.

Balance testing is very detailed. Please be sure to follow the instructions below, otherwise we will be unable to obtain accurate test results which can impair your treatment.

1. Fill out questionnaire on the next page and bring along with you to your appointment

2. Do not take any anti-dizzy medications or anti-nausea medications for a full 48 hours prior to your test. This includes Meclizine, Antivert, Dramamine, Scopolamine patches, Zofran, Phenergan, Bonine, Benadryl or antihistamines. Taking these medications will lead to inaccurate tests results that could lead to incorrect treatment.

3. Do not eat two hours before the test unless you are diabetic. Keep liquids to a minimum.

4. Do not wear any eye make-up or false eyelashes. Make sure all mascara residue is removed. Any make up or even lotion can make the test-results inaccurate.

5. Do not drink ANY alcohol, use illicit drugs, or use marijuana for 48 hours before your test

6. Do not take any sleeping medication (prescription or over-the-counter) for 48 hours prior to test, however, you can continue Melatonin.

7. If you are taking any prescription medications for pain, depression, anxiety, mood disorders, etc., please stop these as well for a full 48 hours UNLESS you have been taking these medications consistently for more than six months. Please inform us at the time of your test whether you were able to stop these types of medications. Please note: Some medications should not be stopped abruptly and you should seek the guidance of your primary physician before stopping your medications.

8. Do not take any allergy or cold medications that makes you sleepy. Non-drowsy formulas are okay. Continue nasal sprays. Do not take antihistamines for 48 hours.

9. CONTINUE all of your life sustaining medications such as water pills, blood thinners, medications for seizures, heart conditions, blood pressure, diabetes, lung or breathing conditions, asthma, kidney or liver problems, etc. You may also continue antibiotics or steroids.

10. Please arrive early for your testing. If you arrive late, we may need to reschedule you. Children and visitors are not allowed in the testing room. Any patient under the age of 18 must be accompanied by a parent or legal guard

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To help us understand your dizziness, please complete the following before your test:

Please mark all the symptoms you are currently experiencing:

Dizziness / Lightheadedness Vertigo (spinning sensation)

Imbalance / Wobbliness Unsteadiness

Sudden “drop attacks” Blacking out or fainting

Describe in your own words your dizzy experience: ________________________________________________________________________________ ________________________________________________________________________________ I. History of Dizzy Episodes

1. When did your problem start? (Date of onset) ______________________________________________

2. Was there any related event? _____________ If yes, what/describe __________________________________________________________________________

3. Was the onset of your problem: Gradual Sudden Overnight Other _________________

4. Is the problem currently: Getting better/improving Same Getting Worse 5. Is your dizziness/imbalance: Constant Comes & goes

If it comes & goesEpisodes occur how often: every: ___hours __ day ___week ____monthEpisodes typically last: ___seconds __ minutes ___hours _____ daysDoes your dizziness/imbalance occur with changes in position or head movements?

Yes NoIf yes, is there a stronger dizzy sensation or tendency towards the Right Left side Both the right and the left sides equally make me dizzy

Cannot differentiate a side6. Do you know of anything that makes your dizziness worse / triggers?

__________________________ _ Loud noises Turning over in Bed Headaches

7. Have you ever fallen due to your problem? Yes No 8. Do you have a history of migraines? Yes No 9. Have you ever had IV antibiotics or chemotherapy? Yes No 10.Have you had any eye, head, neck or back surgery? Please specify.

___________________________________________________________________________

Have you seen any other healthcare professional for this problem (e.g. physical therapist, neurologist)?___________________________________________________________________________

Your body stays in balance through a group effort of your ears, eyes, nerves, joints, and muscles.They each send signals to the brain about body position and head movement. The brain uses this information to balance the body. When you have an inner ear problem, the brain may get conflicting signals. This can cause symptoms such as the feeling of spinning (vertigo).

Inside the inner ear are 3 semicircular canals. Each canal contains tiny hairs, crystals, and fluid. These structures help the canals sense up-and-down, forward and backward, and side-to-side motion. Nerves carry the signals from the canals to the brain.

Signals from throughout your body travel to the brain. Once the signals arrive, the brain decides what they mean. Sometimes signals conflict. Have you ever sat on a stopped train and watched a moving train go by? When that happens, your eyes signal that you're moving. But your inner ear and body signal that you're still. The brain weighs conflicting data such as this and decides what is true. The result is balance.

What treatments are available for my dizziness?

Depending on the cause of your dizziness many treatments are available. You may be surprised to learn that one of the most effective therapies for dizziness is a specialized vestibular physical therapy. The benefit of this is that it has no side effects, is safe, and very effective. The results of your balance testing will help your care team tailor your treatment to your specific disease.

Chesapeake Otolaryngology is proud to be partnering with Fyzical Vestibular Therapy Centers to offer the most scientifically backed, and up-to-date vestibular therapy for our patients.

Finally, missing sound cues can also affect your ability to interact with your surroundings and stay balanced and safe. Based on your hearing test, your care team may recommend hearing aids to also help your balance since hearing and balance are closely associated.

Regardless of the cause of your dizziness, our goal is to allow your physician, your audiologist, and your physical therapist to collaborate in your care to help you feel steady on your feet again.

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