search

Dizziness Diary

Keep track of any dizziness you experience on this form and bring this to your appointment.

For Severity, enter a number from 1 to 10. Use 1 to indicate very mild symptoms and 10 to indicate severe symptoms. In “Other Factors” enter relevant information about what you were doing prior to becoming dizzy and/or what seemed to make the symptoms better.

Date

Symptoms (hearing loss, pressure, dizziness, tinnitus, nausea, vomiting, etc.)

Severity
1-10

How Long it Lasted

Other Factors