VIDEOELECTRONYSTAGMOGRAPHY PATIENT INSTRUCTIONS - PDF document

VIDEOELECTRONYSTAGMOGRAPHY PATIENT INSTRUCTIONS You have been referred to our office for an assessment of your vestibular system. The test is called a Videoelectronystagmography(VNG). A VNG is a test of the balance mechanism. The Antinausea Medicine:Drama AntiVertigo Medicine:Antivert, RuVert, Meclizine, etc… Tranquilizers:Valium, Librium, Atarax, Vistaril, Equinil, Miltown, Triavil, Serax, Etrafon, etc… Sedatives: sleeping pill. Narcotics & BarbituratesPhenobarbital, Codeine, Demerol, Dilaudid, Percodan, Phenaphen, etc… Antihistamines:Chlortrimetan, Dimetane, Disophrol, Benadryl, Actifed, Teldrin, Triaminic or any other over the counter cold remedies. Alcohol in any quantity:Including beer,wine, and any cough medicinesontaining alcohol. Caffeine:discontinue for 24 hours If you have any reservations about discontinuing any medications, consult your doctor. Medication for diabetes, hypertension or heart disease If you have any questions regarding the effect of any medications on the test, please call our office. Sleep a full night before the test.Please eat a light meal approximately two hours before the test.Please do not wear make Patient name___________________________ Date_____________________________DIZZINESS QUESTIONAIREPlease answer all of the following questions by circling or bolding the appropriate responses and/or filling in relevant

blanks.CHARACTERIZE YOUR DIZZINESSYes1. Lightheadedness, faintness, giddiness.Yes No2. Unsteadiness.Yes No3. I or my surroundings seem to be moving.Yes No4. I am able to go on with my usual activities while dizzy.Yes No5. I am able to go on with only some of my usual activities while dizzy.Yes No6. I am completely incapacitated and must go to bed while dizzy. ONSET AND COURSE7. Date of first dizziness_____________________Yes No8. My dizziness is constant.Yes No9. My dizziness come in attacks.10. If in attacks, how often? Hourly Daily Weekly Monthly11. How long do they last? Seconds Minutes Hours DaysYes No12. My dizziness comes on suddenly.Yes No13. My dizziness comes on gradually.Yes NoI am completely free of dizziness between attacks.Yes No15. I can tell when an attack is about to start.Describe how_____________________________ASSOCIATED SYMPTOMSYes No16. Nausea or vomiting?Yes No17. Sweating?Yes18. Deafness or difficulty hearing? Right Ear Left Ear Both EarsYes No19. Any noises(buzzing or ringing in ears)? Right EarLeft EarBothEars Yes No20. Change in this noise with dizziness?Yes No21. Fullness or pain in ears? Right Ear Left EarBoth EarsYes No22. Drainage from ears?Right Ear Left Ear Both EarsYes NoTendency to fall? RightLeftEitherYes

No24. Tendency to veer when walking? Right Left Either Yes No25. Headache or pressure in head? During AfterWhere?_____________________________________Yes No26. Double vision, blurred vision or blindness?Yes No27. Weakness or clumsiness in arms or legs?Yes No28. Difficulty with speech or swallowing?Yes No29. Blackouts, loss of consciousness, confusion or loss of memory?Yes No30. Rapid heartbeat or palpitationYes 31. Shortness of breath during the attack?Yes No32. Numbness or tingling of face, fingers or toes?Yes No33. Pain or stiffness of the neck?EXACERBATING AND REMITTING FACTORSYes No34. Does turning your head bring on or make your dizziness worse?Which direction?_______________________________________Yes No35. Does lying down or sitting up bring on your dizziness?Yes No36. Does standing up bring on your dizziness?Yes No37. Do you find it especially difficult to walk in the dark?Yes No38. Is there any relationship between your dizziness and tension or anxiety in your life?Explain:______________________________Yes No39. Do you know of anything that will precipitate an attacWhat?___________________Yes No40. Do you know of anything that will stop or make your dizziness better? What?_____________________________________________PRESENT/PAST MEDICAL HISTORYYes No41. Have you ever had a concussion,

skull fracture, or been knockedunconscious?Yes No42. Have you ever had a whiplash or do you have a neck disease?Yes No43. Do you have an eye disorder or wear glasses?Yes No44. Have you ever had ear infections or other ear disease?Yes NoHad you been taking prescription or nonprescription medications regularlybefore your dizziness started?If so, list them.____________Yes No46. Do you have any allergies? If so, to what?___Yes NoHave you in the past or do you now smoke? Packs per day____Years_______Yes No48. Have you in the past or are you now a heavy drinker?Yes No49. Have you in the past or do you nowhave: DiabetesHigh Blood Pressure Migraine Seizures Cancer Stroke Heart AttackYes No50. Do you know of any possible cause of your dizziness?What?___________________ Yes No51. Has another doctor done tests to evaluate your dizziness?Dr.________________ Phone ( )_____________ Date___________Yes 52. Do you wear an intracardiac catheter or pacemaker with exposed leads? PLEASE GIVE INSURANCE CARD TO SECRETARY TO COPY____ STATEN ISLAND AUDIOLOGICAL SERVICES Please Print_Clearly Patient: This section refers to the ***patient only*** Name:______________________________________Age:_____Date of Birth:___________Marital Status:______LastFirstAddress:____________________________________Sex:_____ Email address:____________________________City:___________

___State:_______Zip:__________Employer:_________________________________________Home Phone:( )_____________________________Address:__________________________________________Cell Phone: )_____________________________City:____________________State:_____Zip:____________Family Member: ( )__________________________ BILLING: Please complete if person responsible for bill is other than patient** Name:_____________________________________________Relationship to Patient:_______________________LastFirstStreet Address:________________________________________________Insureds Date of Birth:_____________City:_____________________________State:________Zip:________Home Phone:( )_____________________Employer:_______________________________________Address:______________________________________Work Phone:( )____________________City:___________________________State:________Zip:___________ PLEASE SUPPLY US WITH YOUR INSURANCE COVERAGE. If you have more than one carrier, supply information on both. PLEASE LIST ALL NUMBERS ON YOUR CARD(s). Primary Company:______________________________SecondaryCompany:______________________________Address:______________________________________Address:________________________________________Name on I.D.card_______________________________Name on I.D.card_________________________________Relationship to patient (Please check)

Relationship to Patient (Please Check)Self____Spouse____Parent____Other____ Self____Spouse____Parent____Other____Insured I.D. #:_______________________ Insured I.D.#:_______________________Group #:____________________________ Group #:____________________________Signature_______________________________Date__________Referred by_______________________________ PATIENT NAME:__________________ PRIVACY PRACTICES ACKNOWLEDGEMENT I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.Signature: ___________________________________Date: ______________________ QUEST FOR RELEASE OF INFORMATIONI authorize Staten Island Audiological Servicesto release information to the following:Name: _________________________________________________________Address: _________________________________________________________Signature: ____________________________________Date: ______________________ PATIENT’S AUTHORIZATION CERTIFICATION FORMINSURANCE CO: _____________________________ID #: _____________________ I authorize the release of information necessary to file a claim with my insurance carrier and request payment of benefit to either myself or the audiologist, if the fee has not been paid. I understand I am financially responsible for any balance no

t covered by my insurance carrier.Signature: _____________________________________Date: ____________________ INSURANCE CO: MEDICAREID #:_____________________ I request that payment of authorized Medicare benefits be made either to myselfor on my behalf to SI Audiological Services for any services furnished me by that audiologist. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determinebenefits or the benefits payable for related services. I also understand that Medicare does not cover the cost or related cost of a hearing system.Signature: _____________________________________Date:_____________________ ADULT AUDIOLOGICAL HISTORYNAME:___________________Date of Birth:______Age:_______________Referral Source:________________Primary Doctor:_______________________________Occupation(Current or prior to retirement)______________________________Are you experiencing hearing loss? Y N If so, which ear? Right Left BothDuration of hearing loss? ______________ Have you ever worn a hearing aid?Y N If so, for how many years? __________________When was your last hearing test? __________ Where was the test performed?_______________Have you been diagnosed with any of the following: Dementia /Alzheimer’s Parkinson’s diseaseNeurological disorde

rOther:_____________________________________________________ Areyou experiencing memory difficultiesN _________________________________DiabetesY N ___________________________________DizzinessEar Disease/SurgeryWhen?______________Ear Infection/Hole in EardrumTinnitus (Noise/Music in ear)Head Trauma/ConcussionHeart DiseaseKidney or Liver DiseaseChronic Sore ThroatLoss of Sense of SmellCancerHepatitis CAuto Immune DiseaseFamily History of Hearing LossSpinal/Back/Neck issuesSkin DisorderAllergies/AsthmaSeizure disorderSinus diseaseThyroid DiseaseDo you work or have ever worked in a noisy environment? Do you engage in noisy recreational activities such as shooting, riding a motorcycle, attending concerts, playing a musical instrument etc? Have you had an MRI or a CT scan of the head in the past one year? Have you seen an ENT (ear nose and throat) specialistY N If so, when? ________Recent hospitalizations: _____________________________________________________Recent/ New Medication:Other Medical Problems: ________________Comments:___________________________________________________________________PATIENT’S SIGNATUREDATE Please provide COMPLETE list of medication(prescription, over the counter, supplements and vitamins) that you are currently taking.Are you taking blood thinners? N________________________________ Medication Dosage Fre