Audiology - Patient Forms
VIDEONYSTAGMOGRAPHY - PRE-TEST INSTRUCTIONS
For 48 hours before this test do not take any of the following medications:
Anti-dizziness medications (Antivert, Meclazine, Bonine, Dramamine, Marazine, Transdermal Scopolamine Patch etc.)
- Anti-nausea medications (Metociopramide, etc.)
- Anti-seizure medications (Phenobarbital, Dilantin, etc.) **SEE NOTE BELOW**
- Sedatives or sleeping pills (Valium, Librium, Atarax, Tranxene, etc.)
- Decongestants and/or antihistamines
- Antidepressants (Elavil, Triavil, Prozac, Zoloft, etc.)
- Pain Medication (other than regular aspirin, Tylenol, Motrin or Advil)
Do not have any alcoholic beverages for 48 hours before this test.
- Do not smoke for 12 hours before this test.
- Do not have any beverages with caffeine on the day of the test.
- Do not eat or drink anything other than water for 4 hours before this test, unless you are diabetic.
- Do not wear contact lenses.
- Do not wear any face or eye make-up.
**You may continue taking any prescription heart medication, blood pressure medication, insulin and asthma medication. Seizure medication may be taken if unable to be discontinued.**
If you have any questions about your medications, please call 443-849-2142.
This test will last 1 ½ - 2 hours. The test causes no pain, but you may experience some dizziness during the test.
PLEASE CHECK WITH YOUR INSURANCE COMPANY FOR COVERAGE OF THIS TEST. YOU WILL NEED TO BRING YOUR INSURANCE CARD (S) WITH YOU.
FOR HMO PATIENTS - IF YOU DO NOT HAVE AN AUTHORIZAION NUMBER WITH YOU ON THE DAY OF THE TEST, YOU WILL BE RESPONSIBLE FOR PAYMENT OR WE WILL HAVE TO RESCEDULE THE TEST.
If you have any insurance questions, please call 443-849-2142.
THRESHOLD AUDITORY BRAINSTEM RESPONSE EVALAUTION
WITH SEDATION - PRE-TEST INSTRUCTIONS
The parent/caregiver must obtain a doctor's referral for this evaluation. It is your responsibility to verify coverage with your insurance provider and obtain any special authorization or referral (HMO patients). HMO patients: if you do not have a referral with you, we will reschedule you or bill you for the test.
As one parent/caregiver is required to remain with the child throughout this test, do not bring any other children.
Sedation is utilized for this procedure and food and drink must be restricted prior to your child's scheduled time - PLEASE FOLLOW INSTRUCTIONS: No solid food, milk or formula after midnight, No breast milk or clear liquids 3 hours prior to the exam
Sleep deprive your child - put your child to bed later than usual and get up earlier than usual the day of testing. Do not allow a morning nap or snooze in the car on the way here. Sleep depriving your child should facilitate the sedation effect. This is especially important for children older than 18 months. *Please be aware that this sedation may not be effective for your child i.e., does not induce sleep or sleep time is too short to obtain all necessary information.
DO NOT put any cream or lotion on your child's head 24 hours prior to test.
If your child wakes with a fever or cold symptoms, please call the office to determine if appointment should be rescheduled. 443-849-2142
If you fail to show for your appointment within 30 minutes of your scheduled time or without notification of delay, your appointment will be canceled.