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Vertigo

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Vertigo

Please fill in the form completely.

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Patient Information

Full Name *

Age *

Gender *

What is your complaint?

What are your complaints?

I do not have any

Lump in the neck

Pulsatile tinnitus (hearing thumping in ears)

Feeling pressure on your throat

Hoarseness

Other Complaints

Disease History

When did your symptoms start?

Please inform us about the history of your illness:

Did you have a neurological examination, if yes what were you diagnosed with, what suggestions were made?

Your additional diseases:

Previous surgeries (if any):

Please indicate how long have you had your habits, and the amount of consumption.

Please state the medications you take on a regular basis (with doses)

Have you had any previous treatment for this disease?

Did you receive any treatments for this disease before?

I had an operation.

I have received medical treatment

Maneuver was done

Please indicate the surgeries you have had, if there are any.

Please indicate how long have you used your medications and the names of these medications.

Please indicate the ear and the date it was performed

Inspections

Audiometric tests

Balance tests ( VNG, VEMP etc.)

Cephalometric radiolograph tracing report

Imaging (Radiology) Reports

Doppler ultrasound of the neck

MRI of the brain

Laboratory Examinations

Hemogram (Complete Blood Count) Report

Biochemistry Report

I have read and understood the Information and Consent Text regarding the Provision of Remote Healthcare Services and hereby accept its terms.*

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