Dizziness Questionnaire

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

Name

1. Does looking up increase your problem?

YES

SOMETIMES

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

YES

SOMETIMES

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

YES

SOMETIMES

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

YES

SOMETIMES

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

YES

SOMETIMES

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?

YES

SOMETIMES

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

YES

SOMETIMES

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

YES

SOMETIMES

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

YES

SOMETIMES

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

YES

SOMETIMES

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

YES

SOMETIMES

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

YES

SOMETIMES

13. Does turning over in bed increase your problem?

YES

SOMETIMES

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

YES

SOMETIMES

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

YES

SOMETIMES

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

YES

SOMETIMES

17. Does walking down a sidewalk increase your problem?

YES

SOMETIMES

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

YES

SOMETIMES

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

YES

SOMETIMES

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

YES

SOMETIMES

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

YES

SOMETIMES

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

YES

SOMETIMES

23. Because of your problem, are you depressed?

YES

SOMETIMES

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

YES

SOMETIMES

25. Does bending over increase your problem?

YES

SOMETIMES

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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.

YES

What is your name? (not required)

What is your email? (not required)

Click Submit Quiz to see your results!

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