Fyzical - DIZZINESS HANDICAP INVENTORY

Name *

First Name Last Name

Date *

Date

SECTION I
1. Please rate your pain level with activity:

NO PAIN = 0 1 2 3 4 5 6 7 8 9 10 = VERY SEVERE PAIN *

SECTION II - Part I
Instructions: The purpose of this scale is to identify difficulties that you may be experiencing because of your dizziness or unsteadiness. Please indicate answer by choosing “yes or “no” or “sometimes” for each question. Answer each question as it pertains to your dizziness or unsteadiness problem only.

P1. Does looking up increase your problem? *

(1) No (2) Sometimes (3) Yes

E2. Because of your problem, do you feel frustrated? *

(1) No (2) Sometimes (3) Yes

F3. Because of your problem, do you restrict your travel for business or recreation? *

(1) No (2) Sometimes (3) Yes

P4. Does walking down the aisle of a supermarket increase your problem? *

(1) No (2) Sometimes (3) Yes

F5. Because of your problem, do you have difficulty getting into or out of bed? *

(1) No (2) Sometimes (3) Yes

F6. 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) No (2) Sometimes (3) Yes

F7. Because of your problem, do you have difficulty reading? *

(1) No (2) Sometimes (3) Yes

P8. Does performing more ambitious activities like sports, dancing, household chores such as sweeping or putting away dishes increase your problem? *

(1) No (2) Sometimes (3) Yes

E9. Because of your problem, are you afraid to leave your home without having someone accompany you? *

(1) No (2) Sometimes (3) Yes

E10. Because of your problem, have you been embarrassed in front of others? *

(1) No (2) Sometimes (3) Yes

P11. Do quick movements of your head increase your problem? *

(1) No (2) Sometimes (3) Yes

F12. Because of your problem, do you avoid heights? *

(1) No (2) Sometimes (3) Yes

P13. Does turning over in bed increase your problem? *

(1) No (2) Sometimes (3) Yes

F14. Because of your problem, is it difficult for you to do strenuous housework or yard work? *

(1) No (2) Sometimes (3) Yes

E15. Because of your problem, are you afraid people might think you are intoxicated? *

(1) No (2) Sometimes (3) Yes

F16. Because of your problem, is it difficult for you to go for a walk by yourself? *

(1) No (2) Sometimes (3) Yes

P17. Does walking down a sidewalk increase your problem? *

(1) No (2) Sometimes (3) Yes

E18. Because of your problem, is it difficult for you to concentrate? *

(1) No (2) Sometimes (3) Yes

E19. Because of your problem, is it difficult for you to walk around the house in the dark? *

(1) No (2) Sometimes (3) Yes

E20. Because of your problem, are you afraid to stay home alone? *

(1) No (2) Sometimes (3) Yes

E21. Because of your problem, do you feel handicapped? *

(1) No (2) Sometimes (3) Yes

E22. Has your problem placed stress on your relationships with members of your family or friends? *

(1) No (2) Sometimes (3) Yes

E23. Because of your problem, are you depressed? *

(1) No (2) Sometimes (3) Yes

F24. Does your problem interfere with your job or household responsibilities? *

(1) No (2) Sometimes (3) Yes

P25. Does bending over increase your problem? *

(1) No (2) Sometimes (3) Yes

SECTION II - Part II

Instructions: Put a check in the box that best describes you: *

Negligible symptoms (0) Bothersome symptoms (1) Performs usual work duties but symptoms interfere with outside activities (2) Symptoms disrupt performance of both usual work duties and outside activities (3) Currently on medical leave or had to change jobs because of symptoms (4) Unable to work for over one year or established permanent disability with compensation payments (5)

Score= /80

Percentage (%)

DIZZINESS HANDICAP INVENTORY – Initial Visit