Dizziness Handicap Inventory
Instructions: The purpose of this scale is to identify difficulties that you may be experiencing because of your dizziness. Please check “always”, or “no” or “sometimes” to each question. Answer each question only as it pertains to your dizziness problem.
Name
First Name
Last Name
Email
example@example.com
Date
-
Month
-
Day
Year
Date
P1: Does looking up increase your problem?
Always
Sometimes
No
E2: Because of your problem, do you feel frustrated?
Always
Sometimes
No
F3: Because of your problem, do you restrict your travel for business or pleasure?
Always
Sometimes
No
P4: Does walking down the aisle of a supermarket increase your problem?
Always
Sometimes
No
F5: Because of your problem, do you have difficulty getting into or out of bed?
Always
Sometimes
No
F6: Does your problem significantly restrict your participation in social activities, such as going out to dinner, going to movies, dancing or to parties?
Always
Sometimes
No
F7: Because of your problem, do you have difficulty reading?
Always
Sometimes
No
F8: Does performing more ambitious activities like sports, dancing, and household chores, such as sweeping or putting dishes away; increase your problem??
Always
Sometimes
No
E9: Because of your problem, are you afraid to leave your home without having someone accompany you?
Always
Sometimes
No
E10: Because of your problem, have you been embarrassed in front of others?
Always
Sometimes
No
P11: Do quick movements of your head increase your problem?
Always
Sometimes
No
F12: Because of your problem, do you avoid heights?
Always
Sometimes
No
P13: Does turning over in bed increase your problem?
Always
Sometimes
No
P14: Because of your problem, is it difficult for you to do strenuous housework or yard work?
Always
Sometimes
No
E15: Because of your problem, are you afraid people may think that you are intoxicated?
Always
Sometimes
No
F16: Because of your problem, is it difficult for you to go for a walk by yourself?
Always
Sometimes
No
F17: Does walking down a sidewalk increase your problem?
Always
Sometimes
No
E18: Because of your problem, is it difficult for you to concentrate?
Always
Sometimes
No
F19: Because of your problem, is it difficult for you to walk around your house in the dark?
Always
Sometimes
No
E20: Because of your problem, are you afraid to stay home alone?
Always
Sometimes
No
E21: Because of your problem, do you feel handicapped?
Always
Sometimes
No
E22: Has your problem placed stress on your relationship with members of your family or friends?
Always
Sometimes
No
E23: Because of your problem, are you depressed?
Always
Sometimes
No
F24: Does your problem interfere with your job or household responsibilities?
Always
Sometimes
No
P25: Does bending over increase your problem?
Always
Sometimes
No
Signature
Clear
Submit
Should be Empty: