Vestibular Clinic
Intake questionnaire.
Please take 10–15 minutes to complete this form before your first vestibular appointment. Your answers help your physio understand your history and arrive prepared — so you spend your appointment time on assessment and treatment, not paperwork.
Your information is kept strictly confidential and used only to guide your clinical care.
This link appears to be incomplete — it's missing your patient reference. Please use the link sent to you by the clinic, or call us on (02) 4721 5567 for a new link.
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Your story
What is the main symptom that brought you here?
Pick all that fit. There is no wrong answer.
When did this start?
How did it start?
Did anything specific seem to set it off?
Pick all that apply, or "nothing in particular".
Has any clinician given you a specific name for this before?
Pick all that have been mentioned to you.
Episode pattern
How would you describe the way symptoms behave?
How often do episodes occur?
How long does a typical episode last?
Do you get a headache during episodes?
Nausea or vomiting during episodes?
Is it worse when you’re standing up?
Is it worse with motion — walking, riding in cars?
Is it worse in busy visual environments — supermarket aisles, scrolling?
Which positions trigger your symptoms?
How long does the spinning last after triggering?
Triggers
For each item below, indicate how often it triggers or worsens your symptoms.
Sleep deprivation
Stress or anxiety
Specific foods (cheese, chocolate, citrus, MSG, alcohol, processed meats)
Caffeine
Hormonal cycle
Weather pressure changes
Screen time
Busy visual environments (supermarkets, crowds)
Specific head positions or movements
Loud sounds
Air travel
Exercise or physical exertion
Associated symptoms
Do you have a personal history of migraine?
Have you ever had visual aura with a headache (zigzag lines, blind spots)?
Do bright lights or loud sounds bother you during episodes?
Do you have tinnitus (ringing or buzzing in your ears)?
Do you get a feeling of fullness or pressure in one ear?
Do you experience “brain fog” or trouble concentrating along with the dizziness?
Hearing & ears
Have you noticed any change in your hearing?
Was the hearing change sudden — within hours?
If you have tinnitus, is it on one side or both?
Past medical & family history
Does anyone in your immediate family have migraine?
Does anyone in your immediate family have vertigo or dizziness?
Any history of high blood pressure, arrhythmia, or other heart conditions?
Any history of stroke, MS, or significant head injury?
Have you been treated for anxiety, depression, or panic disorder?
This is sometimes relevant — your answer is not used to dismiss your symptoms.
Medications
Are you currently taking any vestibular suppressant (e.g. prochlorperazine, betahistine, Stemetil)?
Are you currently taking a migraine preventer (e.g. propranolol, topiramate, amitriptyline)?
Are you currently taking an SSRI, SNRI or other antidepressant?
Have you started or changed any medications in the last 3 months?
Quality of life
How much has this affected your work?
How much has this affected your driving?
How much has this affected your social life?
How much has this affected your exercise or sport?
How much has this affected your sleep?
How much has this affected your mood?
Anything else you'd like your physio to know?
Optional — any additional context about your symptoms or situation.
Questionnaire received.
Your answers have been saved to your clinical file. Your physio will review them before your appointment so they arrive prepared.
If you haven't already booked, you can do so online or call us on (02) 4721 5567.
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