SSCD SYMPTOM QUESTIONNAIRE Name First Last Date Date Format: MM slash DD slash YYYY 1. Do you experience dizziness or notice an increase in dizziness when speaking in a loud voice or in response to loud noises?YesNo2. Do people mention to you that your speaking voice is soft even though it seems loud to you?YesNo3. Have you ever yelled and felt like you were going to pass out?YesNo4. Do your eyes hurt to move up and down, side to side, or feel like they are scraping or dragging while moving?YesNo5. Have people commented that your eyes twitch or do you feel them twitching?YesNo6. Can you hear your own heart beat inside your head when lying down on one side, when having a severe dizzy episode, or during physical exertion?YesNo7. Do you have a feeling of fullness in one or both ears?YesNo8. When you hum or sing, can you see things move or does it make you dizzy?YesNo9. When you cough or sneeze, do you feel like things are moving or does it make you dizzy?YesNo10. Do you get dizzy when lifting heavy objects or when exerting yourself through exercise?YesNo11. Do you sense that objects on the horizon seem to “bounce”, in your field of vision, while walking/running?YesNo12. Have you ever had the feeling that fluid was leaking out of one of your ears, yet there wasn’t any fluid there?YesNo13. Have you ever felt dizzy when there was a storm front passing through and there was a noticeable change in barometric pressure?YesNo14. Do you feel a constant sway in your body?YesNo15. Do you have ringing in one or both ears?YesNo16. Do you experience dizziness or fullness when lying flat?YesNo
NOTE: On Saturdays, the doctor is available from 9:00 am - 2:30 pm. The Optical Boutique is open from 9:00 am - 4:00 pm.