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Dizzines Handnicap Inventory
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3
Questions
START
HIPAA
Compliance
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English (US)
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1
Date
Today's date
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Date
Month
Day
Year
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2
Unique ID
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3
Name
*
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Full name
Mr.
Mrs.
Mr.
Mr.
Mrs.
Prefix
First Name
Middle Name
Last Name
Suffix
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4
Dizzines Handnicap Inventory
*
This field is required.
Yes
Sometimes
No
Does looking up increase your problem?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Does walking down the aisles of a supermarket without a cart increase your problem?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Does performing more ambitious activities like sports, dancing, or household chores increase your problem?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Do quick head movements increase your problem?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Does turning over in bed increase your problem?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Does walking on the lawn increase your problem?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Does bending over increase your problem?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Because of your problem, do you restrict your travel for business or recreation?
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Because of your problem, do you have difficulty getting into or out of bed?
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Does your problem significantly restrict your participation in social activities?
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Because of your problem, do you have difficulty reading?
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Because of your problem, do you have someone accompany you when you leave home?
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Because of your problem, is it difficult for you to take care of yourself ( i.e. bathe, dress, prepare a meal)?
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Because of your problem, is it difficult for you to walk around your house in the dark?
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Because of your problem, do you avoid driving your car in the daytime?
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Because of your problem, is it difficulty for you to go for a walk by yourself?
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Because of your problem, is it difficulty for you to walk up and down stairs?
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Because of your problem, do you avoid driving your car in the dark?
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
Does your problem interfere with your job or household responsibilities?
Row 18, Column 0
Row 18, Column 1
Row 18, Column 2
Because of your problem, is it difficult for you to concentrate?
Row 19, Column 0
Row 19, Column 1
Row 19, Column 2
Because of your problem, do you feel frustrated?
Row 20, Column 0
Row 20, Column 1
Row 20, Column 2
Because of your problem, are you afraid to stay home alone?
Row 21, Column 0
Row 21, Column 1
Row 21, Column 2
Because of your problem, are you afraid people think you are intoxicated?
Row 22, Column 0
Row 22, Column 1
Row 22, Column 2
Has your problem placed stress on your relationship with members of your family or friends?
Row 23, Column 0
Row 23, Column 1
Row 23, Column 2
Because of your problem, are you depressed?
Row 24, Column 0
Row 24, Column 1
Row 24, Column 2
Does looking up increase your problem?
Does walking down the aisles of a supermarket without a cart increase your problem?
Does performing more ambitious activities like sports, dancing, or household chores increase your problem?
Do quick head movements increase your problem?
Does turning over in bed increase your problem?
Does walking on the lawn increase your problem?
Does bending over increase your problem?
Because of your problem, do you restrict your travel for business or recreation?
Because of your problem, do you have difficulty getting into or out of bed?
Does your problem significantly restrict your participation in social activities?
Because of your problem, do you have difficulty reading?
Because of your problem, do you have someone accompany you when you leave home?
Because of your problem, is it difficult for you to take care of yourself ( i.e. bathe, dress, prepare a meal)?
Because of your problem, is it difficult for you to walk around your house in the dark?
Because of your problem, do you avoid driving your car in the daytime?
Because of your problem, is it difficulty for you to go for a walk by yourself?
Because of your problem, is it difficulty for you to walk up and down stairs?
Because of your problem, do you avoid driving your car in the dark?
Does your problem interfere with your job or household responsibilities?
Because of your problem, is it difficult for you to concentrate?
Because of your problem, do you feel frustrated?
Because of your problem, are you afraid to stay home alone?
Because of your problem, are you afraid people think you are intoxicated?
Has your problem placed stress on your relationship with members of your family or friends?
Because of your problem, are you depressed?
Yes
Row 0, Column 0
Sometimes
Row 0, Column 1
No
Row 0, Column 2
Yes
Row 1, Column 0
Sometimes
Row 1, Column 1
No
Row 1, Column 2
Yes
Row 2, Column 0
Sometimes
Row 2, Column 1
No
Row 2, Column 2
Yes
Row 3, Column 0
Sometimes
Row 3, Column 1
No
Row 3, Column 2
Yes
Row 4, Column 0
Sometimes
Row 4, Column 1
No
Row 4, Column 2
Yes
Row 5, Column 0
Sometimes
Row 5, Column 1
No
Row 5, Column 2
Yes
Row 6, Column 0
Sometimes
Row 6, Column 1
No
Row 6, Column 2
Yes
Row 7, Column 0
Sometimes
Row 7, Column 1
No
Row 7, Column 2
Yes
Row 8, Column 0
Sometimes
Row 8, Column 1
No
Row 8, Column 2
Yes
Row 9, Column 0
Sometimes
Row 9, Column 1
No
Row 9, Column 2
Yes
Row 10, Column 0
Sometimes
Row 10, Column 1
No
Row 10, Column 2
Yes
Row 11, Column 0
Sometimes
Row 11, Column 1
No
Row 11, Column 2
Yes
Row 12, Column 0
Sometimes
Row 12, Column 1
No
Row 12, Column 2
Yes
Row 13, Column 0
Sometimes
Row 13, Column 1
No
Row 13, Column 2
Yes
Row 14, Column 0
Sometimes
Row 14, Column 1
No
Row 14, Column 2
Yes
Row 15, Column 0
Sometimes
Row 15, Column 1
No
Row 15, Column 2
Yes
Row 16, Column 0
Sometimes
Row 16, Column 1
No
Row 16, Column 2
Yes
Row 17, Column 0
Sometimes
Row 17, Column 1
No
Row 17, Column 2
Yes
Row 18, Column 0
Sometimes
Row 18, Column 1
No
Row 18, Column 2
Yes
Row 19, Column 0
Sometimes
Row 19, Column 1
No
Row 19, Column 2
Yes
Row 20, Column 0
Sometimes
Row 20, Column 1
No
Row 20, Column 2
Yes
Row 21, Column 0
Sometimes
Row 21, Column 1
No
Row 21, Column 2
Yes
Row 22, Column 0
Sometimes
Row 22, Column 1
No
Row 22, Column 2
Yes
Row 23, Column 0
Sometimes
Row 23, Column 1
No
Row 23, Column 2
Yes
Row 24, Column 0
Sometimes
Row 24, Column 1
No
Row 24, Column 2
1
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5
Calculation
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6
Signature
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Dizziness Handicap Inventory
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