1255 east 3900 south * suite 106c * slc, ut 84124

5872 South 900 East • Suite 175 • SLC, UT 84121 Office: (801)268-EARS(3277) Fax: (801)268-3288 BALANCE TEST INSTRUCTIONS (VNG/ENG)
You are scheduled to have a test of your balance system on ____________________________________________ at ___________________. Please arrive 10 minutes early to fill out necessary paper work. The test will take approximately 2 (two) hours. The purpose of this test is to further evaluate complaints of dizziness, poor equilibrium, and certain hearing problems. The test attempts to distinguish the source of your problem; one ear, both ears, the brain, or other parts of the balance system. The test is not painful. However, you may feel dizzy for a short time after the test, so we suggest you arrange for someone to drive you home after the testing is complete if you feel that is necessary. In order to obtain the most valid, highest quality results from the test, and for your comfort, you are asked to please comply with the following instructions: 1. The following types of medications interfere with the test and should be discontinued
24 hours prior to the test:
a. Sedatives: Dalmane, Seconal, Nembutal, Phenobarbital
b. Motion Sickness: Antivert, Dramamine, Meclizine, Bonine
c. Antihistamines: Benadryl, Dimetapp, CIM Drixoral
d. Tranquilizers: Valium, Traxene, Xanax
e. Antidepressant Mood Elevators (24 hours prior)
f. Sleeping Pills
g. Diuretics 48 hours(unless being taken for heart disease or high blood pressure)

Do not discontinue medicines prescribed for heart or lung problems, seizures, diabetes, or
blood pressure control.
Please call us if you have any questions.
2. Abstain from alcohol and caffeine for at least 12 hours before the test. Products containing caffeine include many soft drinks, coffee, tea, cola and chocolate. 3. If medically possible, abstain from food and drink for four (4) hours before the test. If you are a
diabetic, or have a similar disorder, eat a light meal and continue your regular routine.
4. You will be asked to remove glasses before testing.
5. Do not wear eye make-up, including liner and mascara. Wear comfortable clothing and flat-heeled
There are two forms behind this letter. Please complete the front and back of each form and bring them with you to your appointment. Please bring your insurance card and identification along with your co-pay. Our office is located at 5872 South 900 East, Suite 175, Salt Lake City, Utah 84121. If you have any
questions, or if you require additional information regarding the test, please call us at (801) 268-EARS (3277). We will be happy to answer any of your questions. We look forward to seeing you! Rocky Mountain Hearing & Balance Center

Source: http://earsutah.com/pdf/Balance_Test_Instructions.pdf


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