Dizziness Handicap Inventory

Full Name *

Today's Date: *

Answer each question as it pertains to dizziness or unsteadiness problems, specifically considering your condition during the last month.

1. Does looking up increase your problem? *

Yes-4

Sometimes-2

No-0

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

Yes-4

Sometimes-2

No-0

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

Yes-4

Sometimes-2

No-0

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

Yes-4

Sometimes-2

No-0

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

Yes-4

Sometimes-2

No-0

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-4

Sometimes-2

No-0

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

Yes-4

Sometimes-2

No-0

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

Yes-4

Sometimes-2

No-0

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

Yes-4

Sometimes-2

No-0

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

Yes-4

Sometimes-2

No-0

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

Yes-4

Sometimes-2

No-0

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

Yes-4

Sometimes-2

No-0

13. Does turning over in bed increase your problem? *

Yes-4

Sometimes-3

No-0

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

Yes-4

Sometimes-2

No-0

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

Yes-4

Sometimes-2

No-0

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

Yes-4

Sometimes-2

No-0

17. Does walking down a sidewalk increase your problem? *

Yes-4

Sometimes-2

No-0

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

Yes-4

Sometimes-2

No-0

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

Yes-4

Sometimes-2

No-0

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

Yes-4

Sometimes-2

No-0

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

Yes-4

Sometimes-2

No-0

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

Yes-4

Sometimes-2

No-0

23. Because of your problem, are you depressed? *

Yes-4

Sometimes-2

No-0

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

Yes-4

Sometimes-2

No-0

25. Does bending over increase your problem? *

Yes-4

Sometimes-2

No-0

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