Name:_____________________________________________________ Age:_____ years
I am right-handed/left-handed (Circle ONE) When is the first time ever in your life you had dizziness? ____________________________________________________________________________________ WHAT were the circumstances?__________________________________________________________ ____________________________________________________________________________________ Currently my dizziness…. (Check all that apply) ( ) is constant ( ) comes and goes ( ) is always there but waxes and wanes If it comes and goes: How long does it typically last?_________________________ seconds/minutes/hours (Circle ONE) How often does it typically occur?__________ times per hour/day/month/year (Circle ONE) My dizziness mostly consists of (Check ALL that apply) ( ) spells of spinning with nausea ( ) off-balance sensation without a dizzy sensation ( ) a light-headed or near-faint sensation ( ) other; Please explain:_______________________________________________________________ Between episodes, I feel (Check ONE): ( ) dizzy or off-balance all the time ( ) normal ( ) other; Please explain_______________________________________________________________ My episodes occur (Check ALL that apply) ( ) spontaneously. Nothing I do seems to bring them on or turn them office ( ) in relation to any head motion ( ) in relation to only certain head positions Describe___________________________________________________________________________ Did you cough, lift, sneeze, fly in an airplane, swim under water, or sustain head trauma shortly before the onset of your dizziness?.YES/NO If you had head trauma prior to your dizziness, did you lose consciousness completely?.YES/NO
PAGE 2, continued When I roll over in bed (Check ONE): ( ) the room spins every time ( ) the room seems to spin sometimes ( ) nothing unusual happens Circle all that apply: I have hearing difficulty……………………………………………………………………………………… Left ear/Right ear I have ringing or other sounds…………………………………………………………………………… Left ear/Right ear
I have fullness……………………………………………………………………………………………………. Left ear/Right ear I have had ear surgery………………………………………………………………………………………. Left ear/Right ear I consider myself to be an anxious or tense type of person: ……………………………………………………………………………………………………………… YES/NO I am under a great deal of stress…………………………………………………………… YES/NO In the past year I have had (CIRCLE): Loss of consciousness…………………………………………………………………………… YES/NO Seizure or convulsion……………………………………………………………………………. YES/NO Slurring of Speech…………………………………………………………………………………. YES/NO Weakness in one hand, arm or leg………………………………………………………… YES/NO Numbness along one side of my body…………………………………………………… YES/NO Double vision…………………………………………………………………………………………. YES/NO Transient loss of vision…………………………………………………………………………… YES/NO Severe pounding headache or migraine…………………………………………………. YES/NO Palpitations of the heart beat…………………………………………………………………. YES/NO Anxiety attacks………………………………………………………………………………………. YES/NO I have or have had (CIRCLE): Diabetes…………………………………………………………………………………………………. YES/NO High blood pressure………………………………………………………………………………. YES/NO Arthritis…………………………………………………………………………………………………. YES/NO Head or neck pain…………………………………………………………………………………. YES/NO Irregular heart beat………………………………………………………………………………. YES/NO Stroke……………………………………………………………………………………………………. YES/NO Please check below for any MEDICATIONS you have tried FOR DIZZINESS or are currently taking:
PAGE 3, continued The effect of Antivert (meclizine) on my dizziness is (Check the ONE that applies): ( ) Never tried it
Regarding my current state of overall function, not just during attacks (Check the ONE that best applies): ( ) 1. My dizziness has no effect on my activities. ( ) 2. When I am dizzy I have to stop what I am doing for awhile, but it soon passes and I can keep going. I continue to work, drive, and engage in any activity I choose without restriction and I have not changed any plans or activities to accommodate my dizziness. ( ) 3. When I am dizzy I have to stop what I am doing for awhile, but it does pass and I keep going. I continue to work, drive, and engage in most activities I choose, but I have had to make some allowance for my dizziness. ( ) 4. I am able to work, drive, travel, take care of my family, or engage in most essential activities, but I must exert a great deal of effort to do so. I must constantly make adjustments in my activities and budget my energies. I am barely making it. ( ) 5. I am unable to work, drive, or take care of my family. I am unable to do most of the active things I used to do. Even essential activities must be limited. I am disabled. ( ) 6. I am unable to walk more than a short distance. Even the simplest activity requires great effort and I am forced to rest afterwards. I cannot take care of my basic needs. I am totally disabled and virtually bedridden.
The fol owing is a listing of Jewish and secular events throughout the school year, that each class wil celebrate. Use the Hebrew Class Key to the right to help you identify which days and with which classes your child wil celebrate any one particular event. Teachers can always use a helping hand, so if you can participate in set-up or clean-up, please let your child’s room p
Standing Orders for Administering Varicella (Chickenpox) Vaccine to Adults Purpose: To reduce morbidity and mortality from varicella (chickenpox) by vaccinating all adults who meet the criteria established by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. Policy: Under these standing orders, eligible nurses and other healthcare professiona