Full Name *

Email *

Phone *

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Please complete this assessment to the best of your ability.

There are no right or wrong answers—this is just to understand your current symptoms.

For each symptom below, rate from 0 to 5:

• 0 = does not affect you at all

• 5 = significantly affects you

1. Dizziness *

1

2

3

4

5

You get dizzy, especially when driving on the freeway or walking in big spaces.

2. Nausea *

1

2

3

4

5

You experience frequent episodes of nausea and/or sickness in vehicles.

3. Anxiety *

1

2

3

4

5

You feel tense, restless, panicked, or worried.

4. Headache *

1

2

3

4

5

You have migraines and/or struggle with frequent headaches.

5. Neckache *

1

2

3

4

5

You experience soreness, stiffness, and/or decreased range of motion in your neck.

6. Unsteady When Walking *

1

2

3

4

5

You feel unsteady when walking or bump into things.

7. Reading Difficulty *

1

2

3

4

5

You struggle with reading speed, comprehension, and/or skipping lines.

8. Sensitivity to Light *

1

2

3

4

5

You get dizzy, especially when driving on the freeway or walking in big spaces.

9. Sensitivity to Sound *

1

2

3

4

5

Everyday sounds seem to bother you.

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