Dizziness Handicap Inventory
Patient's Name:
*
First Name
Last Name
Today's Date:
*
-
Month
-
Day
Year
Date
Please use the pain scale below to rate your pain level with activity:
*
Instructions Part 1
The purpose of this scale is to identify difficulties that you may be experiencing because of your dizziness or unsteadiness. Please indicate answer by selecting "yes", "no" or "sometimes" for each question. Answer each question as it pertains to your dizziness or unsteadiness problem only.
Does looking up increase your problem?
*
1 Yes
2 No
3 Sometimes
Because of your problem, do you feel frustrated?
*
1 Yes
2 No
3 Sometimes
Because of your problem, do you restrict your travel for business or recreation?
*
1 Yes
2 No
3 Sometimes
Does walking down the aisle of a supermarket increase your problem?
*
1 Yes
2 No
3 Sometimes
Because of your problem, do you have difficulty getting into or out of your bed?
*
1 Yes
2 No
3 Sometimes
Does your problem significantly restrict your participation in social activities such as going out to dinner, going to the movies, dancing, or to parties?
*
1 Yes
2 No
3 Sometimes
Because of your problem, do you have difficulty reading?
*
1 Yes
2 No
3 Sometimes
Does performing more ambitious activities like sports, dancing, household chores such as sweeping or putting away dishes increase your problem?
*
1 Yes
2 No
3 Sometimes
Because of your problem, are you afraid to leave your home without having someone accompany you?
*
1 Yes
2 No
3 Sometimes
Because of your problem, have you been embarrassed in front of others?
*
1 Yes
2 No
3 Sometimes
Do quick movements of your head increase your problem?
*
1 Yes
2 No
3 Sometimes
Because of your problem, do you avoid heights?
*
1 Yes
2 No
3 Sometimes
Does turning over in bed increase your problem?
*
1 Yes
2 No
3 Sometimes
Because of your problem, is it difficult for you to do strenuous housework or yard work?
*
1 Yes
2 No
3 Sometimes
Because of your problem, are you afraid people might think you are intoxicated?
*
1 Yes
2 No
3 Sometimes
Because of your problem, is it difficult for you to go for a walk by yourself?
*
1 Yes
2 No
3 Sometimes
Does walking down a sidewalk increase your problem?
*
1 Yes
2 No
3 Sometimes
Because of your problem, is it difficult for you to concentrate?
*
1 Yes
2 No
3 Sometimes
Because of your problem, is it difficult for you to walk around the house in the dark?
*
1 Yes
2 No
3 Sometimes
Because of your problem, are you afraid to stay home alone?
*
1 Yes
2 No
3 Sometimes
Because of your problem, do you feel handicapped?
*
1 Yes
2 No
3 Sometimes
Has your problem placed stress on your relationships with members of your family or friends?
*
1 Yes
2 No
3 Sometimes
Because of your problem, are you depressed?
*
1 Yes
2 No
3 Sometimes
Does your problem interfere with your job or household responsibilities?
*
1 Yes
2 No
3 Sometimes
Does bending over increase your problem?
*
1 Yes
2 No
3 Sometimes
Part 2
Select the option that best describes you:
*
0 Negligible symptoms
1 Bothersome symptoms
2 Performs usual work duties but symptoms interfere with outside activities
3 Symptoms disrupt performance of both usual work duties and outside activities.
4 Currently on medical leave or had to change jobs because of symptoms
5 Unable to work for over one year or established permanent disability with compensation payments
Before submitting please review your answers and make sure you answered them to the best of your ability.
Thank you!
Submit
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