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Section 1
Gender
Male
female
Age
Above 50
Below 50
Are You Hypertensive?
Yes
No
Are You Diabetic?
Yes
No
Do you have a balance problem?
Yes
No
Do you experience double vision or blurred vision that cause vomiting?
Yes
No
Have you experience partial hearing loss associated with dizziness?:
Yes
No
Section 2
Have you been diagnosed with a viral or bacterial infection in the last 2 weeks (cold, flu)?
Yes
No
Do you experience double vision or blurred vision?
Yes
No
Do you drift to one side when walking?
Yes
No
Section 3
Do you experience dizziness while moving your head?
Yes
No
Do you experience dizziness with different body movements, like bending forward or sleeping on your side?
Yes
No
Section 4
Have you been diagnosed with any neurological disorder (Stroke, MS)?
Yes
No
Have you had a head Concussion before experiencing dizziness?
Yes
No
Do you experience lightheadedness or fainting when moving from a sitting to a standing position?
Yes
No
Do you have ear ?
Yes
No
Section 5
How long does your dizziness last?
No
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M
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