Dizziness Intake Form
What a dizziness intake form asks, with sample questions on the sensation, timing, triggers, and related symptoms.
The dizziness intake form on this page records how the dizziness feels, when it started, how long spells last, and what brings them on. The Dizziness Questionnaire from Kaiser Permanente's ENT department in Northern California is one example.
Dizziness intake form, handled by the AI Doctor avatar
AI Doctor, a real-time AI healthcare assistant avatar, asks the questions on a dizziness intake form in the patient's own language, strictly following the practice's instructions.
- Intake before the visit. Patients answer online before they arrive, or at a kiosk when they check in.
- Answers ready for the clinician. Clinicians see what the patient said before the visit starts.
- Less workload at the front desk. Staff spend less time handing out forms and entering answers by hand.
- Key details at a glance. The care team sees what matters up front and decides who needs attention first.
The form becomes a natural conversation: patients answer by talking, in their own words. AI Doctor is an information and patient-assistance interface. It collects answers for the care team to review. It doesn't diagnose, triage, or give treatment advice.
Sample dizziness intake form questions
Typical questions, written out so you can see the level of detail. Every practice words its own form differently.
- Does the room seem to spin?Sensation
- Do you feel lightheaded or faint?Sensation
- When did the dizziness start?Timing
- How long does each spell last?Timing
- Does standing up bring on the dizziness?Triggers
- Do bright lights or loud noises make it worse?Triggers
- Does your hearing change during a spell?Ear symptoms
- Do you notice ringing or ear fullness?Ear symptoms
- Have you had blurred or double vision?Other symptoms
- Have you had numbness in your arms or legs?Other symptoms
- Have you fallen in the past month?Health history
- Do you take medicine for the dizziness?Health history
These are examples to read, not a form to fill in.
Dizziness intake form: FAQ
What does a dizziness intake form ask?
The sample questions on this page are based on the Kaiser Permanente ENT dizziness questionnaire, the CHOP dizziness questionnaire, and Tuality's concussion and vestibular intake. This page groups them into six areas: sensation, timing, triggers, ear symptoms, other symptoms, and health history.
Who fills in a dizziness intake form, and when?
The patient, before the ENT or balance visit. The CHOP version also asks about birth history and school, so it is written for children.
Does it ask about hearing?
Yes. The Kaiser Permanente questionnaire asks whether hearing drops, ringing increases, or ear pressure builds during dizzy spells, and on which side.
Does the form ask about falls?
Yes. Tuality's intake asks whether the patient has fallen in the past month, how many times, and how. The CHOP questionnaire lists frequent falls among its symptoms.
Does the form ask how often spells happen?
Yes. The Kaiser Permanente questionnaire asks how often the dizziness occurs, from several times a day to once a year. The CHOP questionnaire asks how often symptoms occur.
Is there a dizziness intake form template?
The sample questions on this page show a typical set. A practice can adapt them to its own ENT or balance clinic intake.
Does AI Doctor give medical advice?
No. It collects information for the care team. It doesn't diagnose, triage, or recommend treatment.
Can patient answers stay on our own servers?
Yes. RAVATAR offers on-prem deployment: the platform can run inside your own perimeter, so patient answers stay there. RAVATAR complies with GDPR and the EU AI Act.
Set up your AI Doctor in Genesis AI Avatar Studio
Genesis AI Avatar Studio is where you set up, test, and publish AI avatars for your website, mobile app, or Holobox. No coding or technical skills needed.
- 01Choose the AI Doctor avatar.
- 02Add your practice's FAQs and visit information.
- 03Talk to it, then publish it.
