Dizziness Questionnaire - Clarity Hearing Solutions

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Dizziness Questionnaire

DQ

Step 1 of 5

Dizziness Questionnaire 1/5

Please submit this questionnaire prior to your appointment

Patient’s Details:

Gender:(Required)

The following questions refer to your feeling of dizziness. Please fill in all the blanks.

Have you in the past, had an off balance/vertigo/dizzy symptom sensation?(Required)
Do you currrently have an off balance/vertigo/dizzy symptom sensation?(Required)
Do you ever have any of the following sensations?(Required)

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