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Initial Evaluation-VestibularPatient Name:Occupation:Age:Date:1Referring Physician:History of current issue:Date of Onset:What were you doing when it came on?Any changes prior to symptom onset? Medication? Injury? Falls? Illness?Vertigo (spinning/external)?Imbalanced (unsteadiness)?Dizziness (light headed/pass out/internal)?Spontaneous (nothing you think you can do to trigger it) or is it brought on by positional changes or non-specific head movement?Worse with?Lying down in bed, Sitting up in bed,Standing up quickly, Bending forward,How long did your initial episode last?:sec:BPPVSCDRolling over in bed R / LPitching head itisAre there any other symptoms that come along with the dizziness?NauseaVomitingLoss of BalanceVisual changes DysarthriaSensory disturbancesTurning head side to side?day(s):NeuritisLabyrinthitisVestibular ischemiaOscillopsiaLimb PsychiatricHeadache DiplopiaFallsHiccupsWhat relieves your symptoms?Does sneezing, coughing, holding your breath or specific sounds exacerbate your dizziness? Superior Canal DehisenceAssociated sensitivity to lights, sounds or odors with your dizziness? Hormonally triggered? Headaches? Migraine related dizzinessIs your dizziness recurrent?How often does an episode recur?Duration of recurrences?Improving / Worse / Same?Prior treatment?Systems Review:Other current medical issues:Joint pain? Y / NPMH:Neck pain? Y / NBack pain? Y / NHeart conditions ,High Blood Pressure,Hx of infection,Recent antibiotic use,CVA: any residual effects? MS?Hypotension,Osteoporosis,Ability to lie supine for positioning maneuvers if needed? Y / NDM,CA,High CholesterolFalls,HA’s or migrainesHead traumaRed Flags:Have you currently been experiencing unexplained: abnormal fatigue, SOB, slurred speech, difficulty swallowingblurred vision, double vision, numbness tingling, poor coordination, unexplained weight loss/gain,unexplained weakness/ loss of strength in arms/legs, bowel or bladder difficulty,passed out recently or lost consciousness?Hearing Loss? Y / NSide? Y/N: R side/L side/(B)- (Labrynthitis, Menieres, Vestibular schwanomma, SCD)Tinnitus: Right / Left / BilateralHas the loss been gradual or sudden?Hearing test (Audiogram) done recently ? Y / NMedical Tests: MRI (head/neck?) Y/N:CT scan Y/N:Smoke? Y / N:Drink Y / N:
2Physical Exam1.POSTURE/OBSERVATION2. SENSATIONLeft LE :WNL/intactDiminished: Absent:Right LE :WNL/intactDiminished: Absent:3. PROPRIOCEPTIONLeft LE :WNL/intactImpaired: Absent:Right LE :WNL/intactImpaired: Absent:4) MMTLeft LE :WNL/intact Limited:Right LE :WNL/intact Limited:5. CERVICAL SCREENVAST screening: /-AROM: WNL / Limited:PROM: WNL/Limited:UCI testing: /Cervical Dizziness Test: /-Joint Position Sense : /-6. Direction?Head Thrust: WNL/corrective saccade R/LDVA: pre-test line post test line (horizontal) ( or to 2 lines )post test line (vertical) ( or 2 lines )OKN: /- R/LAbnormal ocular ROM:Head Shake without fixation (20 sec): /-Nystagmus/ direction
Initial Evaluation-VestibularDate:7. POSTURAL STABILITY/VSROther Testing:8. GAITStandard :WNLUnsteadyEyes closed: WNL UnsteadyWith head horizontal rotation:With head vertical movements:Tandem gait:WNLWNLWNLUnsteadyUnsteadyUnsteadyComments:9. MOTION SENSITIVITY INDEX(0-10 severity/sec-duration)R EOL EOR ECL ECR CVL CVR CV head rotL CV head rot10. PROVOKED VERTIGO TESTINGIdentification of Posterior / Anterior Canal BPPV11) m-Hallpike Dix:12) Sit Patient up:13) m-Hallpike Dix :14) Sit Patient up:Right WNLRight WNLLeft WNLLeft WNLPosterior Canal BPPVAnterior Canal BPPVRotary torsional nystagmus? Y/NDuration:Transient or prolonged ( 2 min)?Vertigo Y/NNausea Y/NRotary torsional nystagmus? Y/N Duration:Transient or prolonged ( 2 min)Vertigo Y/NNausea Y/NRotary torsional nystagmus? Y/N Duration:Transient or prolonged? ( 2 min)?Vertigo Y/NNausea Y/NRotary torsional nystagmus? Y/N Duration:Transient or prolonged? ( 2 min)?Vertigo Y/NNausea Y/NTorsion ipsilateral to the ear down and upbeatTorsion ipsilateral to the ear down and downbeat3
4Physical ExamIdentification of Horizontal Canal BPPV15) Lateral Body PositionRightWNLLeftWNLGeotropic nystagmus Y/NDuration:Ageotropic nystagmus Y/N Duration:Vertigo Y/NNausea Y/NGeotropic nystagmus Y/N Duration:Ageotropic nystagmus Y/N Duration:Vertigo Y/NNausea Y/NHorizontal Canal BPPV – Canalithiasis- Horizontal geotropic (toward with ground) 2 minHorizontal Canal BPPV–Cupulolithiasis- Horizontal ageotropic (away from the ground) 2 min
Gans Sensory Organization Performance Test etesInner o/motionEvaluationImbalancePositionalvertigoPost treatment1234567KeyN NormalS SwayF FallR RightL LeftPostural Stability PatternNormalCNSVestibularComments Gans SOP Test. All rights reserved. AIB Education Foundation, Inc.11290 Park Blvd., Seminole, FL 33772. Tel: 727.398.5728Multifactorial
Initial Evaluation-Vestibular Date: 3 7. POSTURAL STABILITY/VSR . 4 Physical Exam Identification of Horizontal Canal BPPV 15) Lateral Body Position Right WNL Geotropic nystagmus Y/N Duration:_ Ageotropic nystagmus Y/N Duration: _ .
