Intake form - Brain Balanz

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Please take the time to answer these questions about your symptoms and health:

Step 1 of 6

16%

Please take the time to answer these questions about your symptoms and health:
What best explains your symptoms?
- Brain fog/can’t think
- A False sense of movement of yourself?
- A false sense of movement of the world?
Is the false sense of motion:
- Spinning
- Rocking
- Swaying
- Leaning
Does it have a direction ?
- Yes
- No
Which direction ?
- Left
- Right
- Forward
- Back

With regards to your symptoms:
Is it acute/violent ?
- Yes
- No
How long do the acute episodes last?
- 2-60 sec
- Minutes to 1-hour
- Hours to days
- Weeks
Do you feel that symptoms fluctuate?
- Yes
- No
Do you feel normal between onset of symptoms, for this incident?
- Yes
- No
Have you had this type of incident before?
- Yes
- No
Would you say it is recurrent?
- Yes
- No
Chronic (ongoing for 6 months or more) ?
- Yes
- No
how many years have you suffered symptoms?
Does the sense of movement make you feel
- Sick
- Watery eyes
- Watery mouth
Do you have neck pain?
- Yes
- No
Have you had a concussion?
- Yes
- No
If yes, how long ago
- Days
- Weeks
- Months
- Years
Have you had whiplash?
- Yes
- No
How long ago?
- Weeks
- Months
- Years

With respect to your ears:
Do your ears ever feel full ?
- Yes
- No
Which ear ?
- Left
- Right
- Both
Do your ears ever ring (tinnitus)?
- Yes
- No
Which ear ?
- Left
- Right
- Both
Do you have any hearing loss ?
- Yes
- No
Which ear ?
- Left
- Right
- Both
Is there any correlation with timing of your symptoms and taking a new medication (aspirin, antibiotics, diuretics, etc.)?
- Yes
- No
Is there any correlation with timing of your symptoms and exposure to any environmental chemicals or toxins?
- Yes
- No
Are your symptoms of dizziness worse in the dark?
- Yes
- No
Can your symptoms of dizziness be reduced by visually fixating on a target?
- Yes
- No
Do you ever feel that this problem makes vision blurry/shaky/hard to focus?
- Yes
- No

With respect to your immune system and gut health
Have you ever been diagnosed with an auto-immune disorder?
- Yes
- No
Have you ever been diagnosed with a thyroid disorder?
- Yes
- No
Do you, or anyone in your family, suffer from diabetes?
- Yes
- No
Have you ever suffered from anaemia, or do you have low iron?
- Yes
- No
Do you have any noticeable issues with your gut? E.g. bloating, constipation?
- Yes
- No
Have you got any known intolerances to gluten ?
- Yes
- No

Please answer these questions related to specific vestibular conditions:
BPPV
Do movements provoke your problem?
- Yes
- No
Please select movements:
- Looking up
- Bending down and up
- Rolling over in bed
- Tilting head
Do your symptoms settle within 1 minute
- Yes
- No
Neuronitis
Did your problem come violently and suddenly?
- Yes
- No
Have you had a recent cold/flu/upper respiratory tract infection?
- Yes
- No
Does the onset of this problem seem to correlate with feeling run down?
- Yes
- No
Meniere’s disease
Do you notice a feeling of fullness in the ear accompanying your episodes of dizziness?
- Yes
- No
Do you have ringing in your ear accompanying your episodes of dizziness?
- Yes
- No
Have you experienced two or more episodes of vertigo lasing at least 20 minutes each?
- Yes
- No
Do you have hearing loss on one side ?
- Yes
- No
Vestibular migraine
Do you have headaches with nausea?
- Yes
- No
Do the headaches start on one side?
- Yes
- No
Do you experience flickering light spots (visual aura) before your episodes of dizziness or headaches?
- Yes
- No
Have you noticed your episodes of dizziness can be provoked by stress, low blood sugar levels, diet, chocolate, red wine, caffeine, cheeses or MSG?
- Yes
- No
Have you noticed your episodes of dizziness can be provoked by stress, low blood sugar levels, diet, chocolate, red wine, caffeine, cheeses or MSG?
- Yes
- No
Do you have sensitivity to
- light?
- sound?
Fistula / SCD
Did your dizziness start after trauma to your ear by sudden changes of pressure to your ear?
- Yes
- No
Did your dizziness start after heavy weight bearing or excessive straining with bowel movements?
- Yes
- No
Can sneezing, straining, or changes of pressure trigger your dizziness?
- Yes
- No
Can loud noises or sounds at times trigger your dizziness?
- Yes
- No
Have you started to notice your own voice much louder than before?
- Yes
- No
PPPD
Is your dizziness a non-spinning, vague sensation of rocking, swaying?
- Yes
- No
Has your dizziness been persistent for more than 3 months, on most days?
- Yes
- No
Was there a trigger for these symptoms?
- Yes
- No
Please select:
- Concussion
- Panic attack
- Whiplash
- Acute vertigo
- Migraine
Does movement aggravate your symptoms?
- Yes
- No
Do complex visual environments (e.g. shopping isles) aggravate your symptoms?
- Yes
- No
Do you feel worse when standing and better when lying?
- Yes
- No
MdDS
Did your symptoms start after travelling by sea, land or air?
- Yes
- No
Are you experiencing symptoms of menopause, or irregular menstrual cycle?
- Yes
- No
Have your symptoms of ongoing rocking, bobbing or swaying lasted for more than 1 month?
- Yes
- No
Do you feel better whilst travelling in the car or during passive motion?
- Yes
- No

Visual vertigo (taken from VVAS, Longridge et.al, 2002)
Do you ever feel onset of dizziness from the following?
Walking through supermarket isle
Passenger in car
Walking through shopping mall
Going down escalator
Watching a movie at cinema
Walking over patterned floor

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