First Name *
Last Name *
Your email address *
Family history of similar presentation? Yes No
New symptom? Re-ocurring symptom? New Re-occurring
History of suppressed sneezing or coughing around onset of symptoms? Yes No
History diving in a pool or airplane travel around the time of symptom onset? Yes No
Trauma history prior to onset of symptoms (e.g. car accident, contact in sports)? Yes No
History of infections prior to onset of symptoms (e.g. mumps, measles, mononucleosis)? Yes No
Any symptoms related to ear (e.g. ringing, changes in hearing, burning, fullness)? Yes No
Any facial symptoms (e.g. paralysis, pain)? Yes No
Any eye symptoms (e.g. redness, discharge, pain)? Yes No
History of antibiotic use around time of symptom onset? Yes No
Any sudden falls? Yes No
History of headaches or migraines? Yes No
Unusual head postures (e.g. dental chair, working on car)? Yes No
Prolonged bed rest? Yes No
Exposure to continuous jarring (e.g. aerobics, rough terrain cycling)? Yes No
History of double vision? Yes No
