The Monterey Hearing and Balance Center Custom and Digital Hearing Aids

Michele Ikuta, Licensed audiologist and owner of The Monterey Hearing and Balance Center

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Are you concerned about your balance? If so, complete our

Online Dizziness and Balance Questionnaire

Dizziness has many causes and therefore many treatment options. We recommend that you contact your doctor or a balance diagnostic specialist if you answer “yes” to any of the following questions.


Instructions: 

Please answer all of the questions as they pertain to you. 

Privacy and Security. If you send us an e-mail or submit any forms from this site, you have our assurances that they will be received in confidence and your e-mail address and information will not be shared with any parties outside of The Monterey Hearing & Balance Center.

If you have any questions about the information that is made available on this site, please call us or contact the Site Administrator.


First name:

Please send my results via email to:

Confirm email address:

Please call to discuss my results. Telephone number:  

1.  Do you feel unsteady when you move suddenly?

Yes, most of the time
Yes, sometimes
Maybe
No, almost never
No, this never happens

2.   Are you dizzy when you get out of bed or up from a chair too quickly?

Yes, most of the time
Yes, sometimes
Maybe
No, almost never
No, this never happens

3.   Do you have balance concerns when walking or climbing stairs?

Yes, most of the time
Yes, sometimes
Maybe
No, almost never
No, this never happens

4.  Do you have difficulty sitting down or standing up?

Yes, most of the time
Yes, sometimes
Maybe
No, almost never
No, this never happens

5.  Have you had one or more fainting spells or black outs in the past year?

Yes
No 

6.  Have you fallen more than once in the past year?

Yes
No 

7.  Do you sometimes experience numbness in your legs, feet or fingers?

Yes, often
Yes, sometimes
Maybe
No, almost never
No, this never happens 

8.  Do you experience earaches?

Yes, often
Yes, sometimes
Maybe
No, almost never
No, this never happens 

9.  Have you had a virus or ear infection in the past year?

Yes
No 

10.  Do your ears often get blocked by wax?

Yes, often
Yes, sometimes
Maybe
No, almost never
No, this never happens 

11.  Do you take medications for more than one of the following health issues: 
high blood pressure, anxiety, cardiac condition or depression?

Yes
No

12.  Have you had a stroke?

Yes
No

13.  Did you have a head trauma prior to your dizziness? 

Yes
No

14.  Do you have occasional loss of vision or double vision?

Yes, often
Yes, sometimes
Maybe
No, almost never
No, this never happens 

15.   Do you suffer from pounding headaches or migraines? 

Yes, often
Yes, sometimes
Maybe
No, almost never
No, this never happens 

If you answered yes to five or more of the above questions you should probably schedule a visit with a qualified audiologist. To have a representative from The Monterey Hearing & Balance Center contact you, please click the "Submit" button below. Or, send a question to Michele in the box below.

 

 

Serving the Monterey
Peninsula for 50 Years

1077D Cass Street
Monterey, California

831.375.5688

Map to Office

Email Us

Office Hours
Monday - Friday 9-5pm
Closed 12 - 1:30 for lunch

Payment Options

 

 

     

Do you have a question about dizziness or balance? Or would you like to add your comments about this balance test? Send a message to Michele and The Monterey Hearing and Balance Center here:


Privacy and Security. If you send us an e-mail or submit any forms from this site, you have our assurances that they will be received in confidence and your e-mail address and information will not be shared with any parties outside of The Monterey Hearing & Balance Center.

If you have any questions about the information that is made available on this site, please call us or contact the Site Administrator.

 


 
 


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