Dizziness and imbalance are common complaints in the elderly, with etiologies ranging from benign (e.g., benign paroxysmal positional vertigo) to potentially life-threatening (e.g., cerebellar stroke). Therefore, the stakes can be high and an organized and methodical approach to the history and examination is essential. The days of classifying based on the symptom quality alone – “dizzy,” “vertigo,” “lightheadedness” – are over, as this approach is often misleading and can result in an incorrect diagnosis. Instead, identifying the timing and onset, duration, triggers, and associated symptoms allows the clinician to substantially narrow the differential diagnosis. From the history, a focused examination is be performed depending on the clinical scenario (e.g., Dix-Hallpike for positional vertigo; the “HINTS” exam in the acute vestibular syndrome), and the most appropriate test(s) can then be selected when appropriate. In the elderly, there are many potential non-neuro-vestibular contributors that must also be considered (e.g., polypharmacy, blood pressure), and to complicate the history and examination further, dizziness and imbalance are often multifactorial. This chapter offers a practical step-by-step approach to the evaluation of elderly patients presenting with balance and vestibular disorders.