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Introduction

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Name: __________ Date: __________

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The purpose of this scale is to identify difficulties that you may be experiencing because of your dizziness or unsteadiness. Please check Yes, No, or Sometimes for each question. Answer each question as it pertains to your dizziness or unsteadiness only.

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Yes No Sometimes
  • P1. Does looking up increase your problem?

____ ____ ____
  • E2. Because of your problem, do you feel frustrated?

____ ____ ____
  • F3. Because of your problem, do you restrict your travel for business or recreation?

____ ____ ____
  • P4. Does walking down the aisle of a supermarket increase your problem?

____ ____ ____
  • F5. Because of your problem, do you have difficulty getting into or out of bed?

____ ____ ____
  • F6. Does your problem significantly restrict your participation in social activities such as going out to dinner, the movies, dancing, or to parties?

____ ____ ____
  • F7. Because of your problem, do you have difficulty reading?

____ ____ ____
  • P8. Does performing more ambitious activities like sports or dancing or household chores such as sweeping or putting dishes away increase your problem?

____ ____ ____
  • E9. Because of your problem, are you afraid to leave your home without having someone accompany you?

____ ____ ____
  • E10. Because of your problem, are you embarrassed in front of others?

____ ____ ____
  • P11. Do quick movements of your head increase your problem?

____ ____ ____
  • F12. Because of your problem, do you avoid heights?

____ ____ ____
  • P13. Does turning over in bed increase your problem?

____ ____ ____
  • F14. Because of your problem, is it difficult for you to do strenuous housework or yardwork?

____ ____ ____
  • E15. Because of your problem, are you afraid people may think you are intoxicated?

____ ____ ____
  • F16. Because of your problem, is it difficult for you to walk by yourself?

____ ____ ____
  • P17. Does walking down a sidewalk increase your problem?

____ ____ ____
  • E18. Because of your problem, is it difficult for you to concentrate?

____ ____ ____
  • F19. Because of your problem, is it difficult for you to walk around your house in the dark?

____ ____ ____
  • E20. Because of your problem, are you afraid to stay home alone?

____ ____ ____
  • E21. Because of your problem, do you feel handicapped?

____ ____ ____
  • E22. Has your problem placed stress on your relationships with members of your family or friends?

____ ____ ____
  • E23. Because of your problem, are you depressed?

____ ____ ____
  • F24. Does your problem interfere with your job or household responsibilities?

____ ____ ____
  • P25. Does bending over increase your problem?

____ ____ ____
Total ____ ____ ____
(4) (0) (2)
Total: __________ F __________ E __________ P __________
                    (36)                (36)                (28)

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Appendix Reference

1. +
Jacobson  GP, Newman  CW. The development of the dizziness handicap ...

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