In article <Pine.OSF.3.90.960228003552.31610A-100000 at arriba.nm.org>,
snscheli at arriba.nm.org says...
>>Tom, do you have a standard case hx form that you use for your ENG Hx.
>If you do I would like a copy of it. ...That is If you have it in
>"electromedia" that can be transmitted through the internet.
Yup. The ASCII version is at the bottom of this message. The
WordPerfect formatted vesrion is much prettier, but you'll get the idea. If
you want the formatted version, let me know what word processor you use, and
I'll try to convert it and send it to you as an email attachment (if your
email program can accept UUencoded attachments, that is...)
Most of this data gets entered into a patient database along with balance test
findings so we can do clinical research.
Note that the real(formatted) form has lots of blank space for writing, the
stuff in parentheses is just reminders of what to note down.
The code for auditory symptoms is AU=bilateral, AS=left, AD=right, NN=none
The disability scale is used to track progress over time, i.e does the patient
report less disability (lower #) following treatment.
--------------------------------------------------------------
UNIVERSITY OF MICHIGAN HOSPITALS, VESTIBULAR TESTING CENTER, DEPARTMENT OF
OTOLARYNGOLOGY
Onset: (date of onset; describe circumstances; sudden vs gradual; past hx;
previous dx.)
Characteristics:(objective or subjective vertigo, r or l; nausea / emesis;
unsteady / falls; lightheaded / LOC; hot / cold / diaphoretic; heart rate or
; panic; headache; spells or continuous sx.)
f in spells: [A: Spontaneous and/or B: Motion Provoked (x/day, lasting ? min);
what symptoms w/A & B?; spells start suddenly or gradually; prodrome.]
If continuous: (unsteady; lightheaded; vertigo; other; laying, sitting,
standing, and/or walking.)
Predisposing factors: (Yes/No)
head injury: neck injury: ototoxic drugs: toxic chem:
flu/virus: migraine self: migraine fam: D.M. Self:
D.M. Fam: eye disease: hypertension: peripheral vasc:
heart disease: neuromuscular: orthopedic: barotrauma:
Auditory sx: (AS AD AU EQ NN)
tinnitus: if AU, tinnitus greater in: constant / episodic
aural fullness: if AU, fullness greater in: constant / episodic
perceived hearing loss; sudden (permanent change):
fluctuant (up and down): gradual (progressive):
(which ear is worse?) _____
_____ _____
Ear Surgery: (circle one) AS AD AU None describe procedures:
Middle Ear dx (pain and/or drainage):
Family history of vertigo/balance sx: (diagnosis?)
Positioning sx: (circle all that apply; frequency and duration)
lay down from sitting sit up from laying
roll r or l in bed
stand up from sitting turn head r or l
bend over
straighten from bending look up or down
others: (describe)
Motion intolerance:
car sickness (now, and past hx) sx on elevators or escalators
sx in store aisles sx while standing near traffic
others: (describe)
Miscellaneous:
increase in sx or frequency/duration of attacks with physical exertion.
Oscillopsia:
loss of consciousness:
falling (or sx of imminent fall, and direction):
numbness or tingling in face or extremities:
visual sx:
memory lapse:
nervousness scale: /10
ETOH/other drug use:
others: (describe)
Current medications:
Disability scale: (for current vertigo and balance symptoms only, not for
other disorders!)
0 No disability, no symptoms.
1 No disability, bothersome symptoms.
2 Mild disability, performs usual duties,
3 moderate disability, disrupts usual duties.
4 recent severe disability, on medical leave or had to change job.
5 long term severe disability, unable to work for past year or longer.
but symptoms interfere with social activities.
COMMENTS:
T. Boismier 03/29/95
