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Balancepointindy.com

5255 E. Stop 11 Road, Suite 405Indianapolis, IN 46237 Page 1 of 5
A Division of Otolaryngology Associates Pre-Appointment Packet Balance Point Assessment Insurance Information
Your doctor has recommended Balance Function Testing to help determine the cause of your symptoms of dizziness, motion sickness, and/or unsteadiness. The findings help guide your doctor in choosing the best form of treatment. The testing is described briefly on the description and instruction form included in this packet. Balance Function Testing appointments are scheduled for two hours, though may be shorter. As the testing proceeds, the results are evaluated and decisions are made about how much additional testing should be performed. One or more tests may not be completed if it is determined that they are not needed, or if the patient is unable to perform them. If you have had BALANCE TESTING elsewhere within the past year, please bring copies of the test results with you. We will look at these results and decide if any of the tests do not need to be repeated. Cancellation Policy: We have allotted time on our schedule for you to have certain testing ordered by your physician. If you are
unable to keep this appointment, you should notify us at least 24 hours in advance by calling the Balance Point office at 317-807-0744.
You may be subject to a missed appointment charge of $35.00 if you do not arrive to your scheduled appointment.
Payment Policy: At Balance Point our relationship is with you, not your insurance company. While the filing of insurance claims is a
courtesy that we extend to our patients, you are personally responsible for knowing your policy benefits and any amount not covered
by your insurance.
Most insurance companies cover these tests. If you have concerns about whether your insurance company will pay for these tests, it is your responsibility to contact them. To assist you with this, we have listed all the CPT procedure codes used in the Balance Function Testing below. The insurance company will need these codes to answer your questions. Description
Number of Units Tested
Comprehensive Hearing Evaluation Comprehensive Vestibular Evaluation Caloric Irrigation Sinusoidal Rotation Auditory Evoked Potential-Complete Unspecified Otolaryngology Procedure; VEMP test 5255 E. Stop 11 Road, Suite 405Indianapolis, IN 46237 Page 2 of 5
A Division of Otolaryngology Associates Pre-Appointment Packet Description of Vestibular Testing
VNG: The full name of the test is videonystagmography. This test shows us whether both inner ears of balance are equally strong. We
will ask you to follow moving lights with your eyes. We will have you lay down on a table the same way you would in bed. Lastly, we
will gently flow warm or cool water in your ears and record your eye movements. This test lasts approximately 1 hour.
Rotary Chair Test: For this test, you will sit in a computerized swivel chair. We will record your eye movements as the chair swivels
back and forth in a dark room. This test is tolerated very well and takes approximately 30 minutes.
VEMP: The full name of the test is Vestibular Evoked Myogenic Potential. The VEMP test provides us with information about how the
balance parts of the inner ear called the saccule and utricle are functioning. We will have you lay down on a table and lift your head
up while you listen to a "beep". We will also have you look upwards when you hear the "beep". This test lasts approximately 30
minutes.
CHAMP/ABR: This is a specialized test that does not require you to either listen to the sounds or respond to them in any way. We will
place on your head the same types of wires that are used to record brain waves. We will place earphones in your ears through which
you will hear clicking sounds. The sounds will be loud but not loud enough to do any harm.
Hearing Evaluation: We will ask you to repeat back to us both soft words and words that are comfortably loud. We will also ask you
to respond when you hear very soft pulsating tones in your ears.
Instructions for Vestibular Testing
• For VNG and rotational chair testing, if you are already unsteady we suggest you bring someone with you that can drive you home after the testing is completed.
• Certain medications may interfere with results of the VNG and rotational tests. We ask that you take only essential medications during the 2 days before your appointment. Examples of essential medications include: heart medicines, blood pressure medicines, diabetes medicines, seizure medicines, and psychiatric medicines. • We ask that you avoid the following for 48 hours prior to testing: alcoholic beverages, sleeping pills, tranquilizers,
narcotics, antihistamines, and medications for your dizziness. Some of these medications include: Meclizine, Antivert, Bonine, Dramamine or generic, Transderm Scop Patch, Valium (Diazepam), Lorazepam, Ativan, Xanax (Alprazolam), Clonazepam (Klonopin), sleeping pills, Robinul, Donnatal. • Many different foods and beverages can affect the results of the tests, therefore, we ask that you do not eat anything the morning of your test. If your test is scheduled in the afternoon, please only eat a small meal in the morning. If you are diabetic you may eat a small meal (example: toast and juice) on the morning of your test. • Please do not wear makeup (especially eye makeup) or facial moisturizer. • Please bring a list of all medications you are taking.
5255 E. Stop 11 Road, Suite 405Indianapolis, IN 46237 Page 3 of 5
A Division of Otolaryngology Associates Pre-Appointment Packet Please bring the following completed paperwork in order to be evaluated in a timely fashion.
Dizziness Questionnaire (Furman, Cass, & Whitney 2010)
Characteristics of Dizziness
Is your dizziness associated with any of the following sensations? Please read the entire list first, then circle yes
or no to describe your feelings most accurately.
Yes
No 1. Lightheadedness or swimming sensation in head No 2. Blacking out or loss of consciousness No 3. Tendency to fall No 4. Objects spinning or turning around you No 5. Sensation that you are turning or spinning inside, with outside objects remaining stationary No 6. Loss of balance when walking in the light: Veering to the Right? No 7. Loss of balance when walking in the dark: Veering to the Right? 11. Pressure in the head 12. Tingling in the fingers or toes 13. Tingling around the mouth Associated Ear Symptoms
Do you have any of the following symptoms? Please circle yes or no and circle the ear involved, if applicable.
Yes No 1. Dizziness. Please describe dizziness.
No 2. Difficulty in hearing? No 3. Does your hearing change with dizziness? If so, how? 4. Do you have noise in your ears? No 5. Does noise change with dizziness? If so, how? No 6. Do you have fullness or stuffiness in your ears? No 7. Do you have pain in your ears? No 8. Do you have a discharge from your ears? 5255 E. Stop 11 Road, Suite 405Indianapolis, IN 46237 Page 4 of 5
A Division of Otolaryngology Associates Pre-Appointment Packet Time Course and Aggravating Factors
1. When did your dizziness first occur?2. How often do you become dizzy?3. If dizziness occurs in attacks, how long does an attack last?Yes No 4. Do you have any warning that dizziness is about to start? No 5. Does dizziness occur at any particular time of the day or night? No 6. Are you completely free of dizziness between attacks? No 7. Does change of position make you dizzy? Which movements? No 8. Do you become dizzy when rolling over in bed? No 9. Do you know of any possible cause for your dizziness? What? No 10. Do you know of anything that will: a. Stop your dizziness or make it better? b. Make your dizziness worse? No 11. Do you become dizzy when you bend your head forward? Backward? No 12. Do you become dizzy when you cough? When you sneeze? When you have a bowel movement? 13. Can any of the following make your dizziness worse or start an attack? Menstrual period? Emotional upset? No 14. Do you have any allergies? What? Associated Neurologic Symptoms
Have you experienced any of the following symptoms? Please circle yes or no and circle if constant or in episodes.
Yes No 1. Double vision No 2. Blurred vision No 4. Numbness of the face or extremities No 5. Weakness in the arms or legs No 6. Confusion or loss of consciousness No 7. Difficulty with speech No 8. Difficulty with swallowing No 9. Pain in the neck or shoulders 5255 E. Stop 11 Road, Suite 405Indianapolis, IN 46237 Page 5 of 5
A Division of Otolaryngology Associates Pre-Appointment Packet Past Medical History, Family History, Social History
No 1. Did you have a history of earaches or ear infections as a child? No 2. Did you ever injure your head? When? No 3. Were you ever unconscious? When? No 4. Did you suffer from motion sickness before the age of 12? No 5. Have you suffered from motion sickness in the last 10 years? No 6. Do you now take any medications regularly? What? No 7. Have you taken medications in the past for dizziness? Which ones? 8. Do you have a past medical history of: High blood pressure? Migraine headache? 9. Do you have a family history of: Neurologic disease? Migraine headache? No 10. Do you use tobacco in any form? What kind? How much? No 11. Does caffeine affect your dizziness? How? No 12. Does alcohol affect your dizziness? How?

Source: http://www.balancepointindy.com/Documents/Balance%20Point%20Pre-Appointment%20Packet.pdf