Enter the name of the physician if you were referred to The Dizzy Clinic. If you were not referred, how did you hear about The Dizzy Clinic?
ie- getting out of bed, driving.
ie- minutes, hours, days, constant, intermittent.
ie- Physical Therapy, Acupuncture, Medications. Please describe.
Please describe any falls in the past year.
If applicable, please describe pain location.
Add any information that you feel may be important.