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Dizziness Questionnaire

If you or a loved one experiences dizziness, unsteadiness or motion sensitivity, take this quiz to help us understand your symptoms.

Name

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1. Does looking up increase your problem?

2. Because of your problem, do you feel frustrated?

3. Because of your problem, do you restrict your travel for business or recreation?

4. Does walking down the aisle of a supermarket increase your problems?

5. Because of your problem, do you have difficulty getting into or out of bed?

6. Does your problem significantly restrict your participation in social activities, such as going out to dinner, going to the movies, dancing, or going to parties?

7. Because of your problem, do you have difficulty reading?

8. Does performing more ambitious activities such as sports, dancing, household chores (sweeping or putting dishes away) increase your problems?

9. Because of your problem, are you afraid to leave your home without having without having someone accompany you?

10. Because of your problem have you been embarrassed in front of others?

11. Do quick movements of your head increase your problem?

12. Because of your problem, do you avoid heights?

13. Does turning over in bed increase your problem?

14. Because of your problem, is it difficult for you to do strenuous homework or yard work?

15. Because of your problem, are you afraid people may think you are intoxicated?

16. Because of your problem, is it difficult for you to go for a walk by yourself?

17. Does walking down a sidewalk increase your problem?

18. Because of your problem, is it difficult for you to concentrate?

19. Because of your problem, is it difficult for you to walk around your house in the dark?

20. Because of your problem, are you afraid to stay home alone?

21. Because of your problem, do you feel handicapped?

22.  Has the problem placed stress on your relationships with members of your family or friends?

23.  Because of your problem, are you depressed?

24. Does your problem interfere with your job or household responsibilities?

25. Does bending over increase your problem?

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Would you like to email us this report for further diagnosis during your appointment?  If YES, enter your email below and click “Submit Quiz”. If NO, skip the name and email section, and instead click “Submit Quiz” to see your instant results.

What is your name? (not required)

What is your email? (not required)

Click Submit Quiz to see your results!

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