This test is used by Lifeline’s vestibular therapist to evaluate an individual’s dizziness level, with aspects of physical, emotional, and functional limitations. The word “problem” refers to dizziness or unsteadiness.

Answer “YES”, “SOMETIMES”, or “NEVER”
 

1. Does looking up increase your problem?
    
2. Because of your problem do you feel frustrated?
    
3. Because of your problem, do you restrict travel for business and/or recreation?
    
4. Does walking down the aisle of a supermarket increase your problem?
    
5. Because of your problem, do you have difficulty reading?
    
6. Does your problem significantly restrict your participation in social activities, such as going out to dinner, movies, dancing, or parties?
    
7. Because of your problem, do you have difficulty reading?
    
8. Does performing more ambitious activities like sports, dancing, and household chores, such as sweeping or putting dishes away, increase your problem?
    
9. Because of your problem, are you afraid to leave your home 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. Does your problem make it hard for you to do strenuous house/yard work?
     
15. Because of your problem are you afraid people may think you are drunk?
     
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 your 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?
     

Score:
4 points for “YES”
2 points for “SOMETIMES”
0 points for “NEVER”
 

TOTAL POINTS  ______

Any points accumulated could be a problem: you may email or bring in this form for the vestibular therapist to evaluate. The test is designed to illuminate areas that dizziness and balance problems may affect one’s life. (credit the questionnaire to Jacobson and and, Newman,1990)