Dizzy/ Vertigo Rod

Dizziness
Starting [text] before this evaluation
Onset while [text].
Episode description: [text]

Improving factors: [text]
Worsening factors [text]

[select value="no|YES"] <-- vertigo [text]
[select value="no|YES"] <-- hearing loss [text]
[select value="no|YES"] <-- tinnitus [text]
[select value="no|YES"] <-- lightheadedness [text]
[select value="no|YES"] <-- ataxia [text]
[select value="no|YES"] <-- near-syncope [text]
[select value="no|YES"] <-- confusion [text]
[select value="no|YES"] <-- palpitations [text]
[select value="no|YES"] <-- nausea or vomiting [text]

[select value="no|YES"] <-- chest pain [text]
[select value="no|YES"] <-- dyspnea [text]
[select value="no|YES"] <-- Recent upper respiratory infection [text]
[select value="no|YES"] <-- Ear ache [text]
[select value="no|YES"] <-- headache [text]
[select value="no|YES"] <-- visual changes [text]
[select value="no|YES"] <-- abdominal pain [text]
[select value="no|YES"] <-- bleeding 
[select value="no|YES"] <-- Hx of anemia
[select value="no|YES"] <-- Hx of DM or low blood sugar [text]

Pertitner hx
[checkbox name="variable_1" value=" No concerns about pregnancy|Concerns about pregnancy|previous similar episodes"][text]

Treatment 
[text]