This is a complex testing that will help your doctor determine why you are dizzy and off balance and perhaps falling. It will give your doctor valuable information; however, a lot depends on your cooperation.

Imbalance and falling are very difficult problems. The human ability to maintain an erect posture and move about without becoming dizzy takes a lot of integration of the nervous system. The inner ear sends messages into the brain stem to tell us where we are in space. This will be tested, for example, by the”Dix-Hallpike” and other similar maneuvers. This maneuver is performed when the head and body are in a down position. A stream of air, warm and cool, will go into the ears to stimulate the ear drums. The other tests that we do will to find out whether the brain stem and brain balance mechanisms are working well. These call for your visually tracking an object from side to side across a T.V. screen. You will also have some testing done with balance analysis on the fall-track device where you stand on a platform. It is through this information and your cooperation with the testing that your doctor can make a more accurate diagnosis and know how to treat you in a more precise manner

This test has a lot to do with vision and inner ear functions. You will be supplied with a pair of goggles (not unlike the kind helicopter pilots’ use). These goggles let you see out of one eye and you will do certain maneuvers with them. One of the maneuvers is moving your head back and forth from left to right. Another of the maneuvers is moving your head up and down. You will also track a little hourglass figure on a TV screen and it will show how your eyes pursue different targets. Another test called the Dix-Hallpike maneuver is where with goggles on you will be asked to lay down (you will have vision in one eye almost at all times) and turn your head left and right. This allows the technician to see if there is any nystagmus (jerkiness) in the eyes which might imply some problems with the inner ear mechanisms. Part of the test includes putting some warm and colder air into your ear. The inner ear is very sensitive to this maneuver and eyes will usually draw to that side when the appropriate warm or cold stimulus is used. The eyes may then try to pull away. This test will be done only after your ear is inspected to make sure there is no wax build up.

Part of the checking has to do with your standing on a balance measurement device. It is a large circle about one yard around and it is fixed in a very stable position. Once you have your balance, you will then follow with your body and eyes a moving target on a T.V. screen, with the target going in circles, clockwise and counter clockwise. The floor pressure can be varied to make it somewhat moveable. Once you are balanced, the move ability will be tracked to see how good you can keep following a little circle (like the “Pac-Man”) around with your body and feet moving this little platform in various directions. When you get good at it and if you enter balance therapy, training exercises are done which will allow you to be able to see the T.V. target in and out of a maze with your body movements. This “Sportal device” will help train your balance. There is a rail in front of it that you can hold onto if needed. The technologist who is doing the test will watch you very carefully to make sure you do not become unbalanced.

PLEASE REFRAIN FROM ANY CAFFEINE/ALCOHOL 24 HOURS BEFORE THE TEST. PLEASE DO NOT TAKE ANY MECLIZINE/ANTIVERT/BENADRYL/ZYRTEC OR ANY ANTIANXIETY MEDICINES 48 HOURS PRIOR TO THE TEST.

We would like for you to fill out this 12 question form which tells the doctor about some of your problems with dizziness, your inner ear and your balance. if you feel up to it, we will ask you if you can do one small maneuver putting one foot in front of the other to see how your balance is on a narrow base.

We want you to feel perfectly at home and at ease having first read this information. Feel free at any time to ask the technologist any questions about it. She is quite familiar with the testing procedure. You are able to stop the test anytime if you do not feel comfortable or able.

Please let us know at anytime if you have any difficulties before, during or after the studies. Most people do not have any difficulty whatsoever. Some of them enjoy it as a fun workout or like walking a treadmill machine.

This test might make you dizzy, please bring someone with you if you think you may not be able to drive after the test. The test does take about one hour

Please feel free to call the office if you have any questions that are not answered by this information.

4. Do you have hearing loss? Y N Ringing in your ears? Y N . And dizziness all mixed together? Y N

5. Do you have spells of dim vision in one or both eyes along with weakness on one side of the body

7. Do you ever experience imbalance with dim vision and trouble speaking with weakness of one or

9. Have you ever had a transient ischemic attack (TIA) and what were the symptoms? Y N

10. Are you taking medicines now that might make your blood pressure go down such as blood pressure

medications? Y N Names of medication____________________________________________

11. Have you ever taken the medicine gentamicin or streptomycin? Y N When?__________________

The most important question is are you able to stand by yourself with one foot in front of the other, arms crossed, with eyes closed for 10 seconds? If you think you can do it and have the control and ability, let the operator know that. Make sure someone is watching you so that no injury or fall can occur. We do not want you to hurt yourself.

We thank you for your cooperation. This clinical information will help us to make a better diagnosis.

Patient Signature__________________________________________ Date___________________