You can always press Enter⏎ to continue
Discover Your Dizziness Severity in Under 2 Minutes
All information is encrypted and HIPAA compliant
16
Questions
START
HIPAA
Compliance
1
Name
First Name
Last Name
Previous
Next
Submit
Press
Enter
2
Phone Number
Please enter a valid phone number.
Previous
Next
Submit
Press
Enter
3
Email
example@example.com
Previous
Next
Submit
Press
Enter
4
I have...
Dizziness
Tinnitus
Vertigo
Hearing Loss
Imbalance
Headache
Previous
Next
Submit
Press
Enter
5
Does looking up increase your problem?
*
This field is required.
1/10
Yes
Sometimes
No
Previous
Next
Submit
Press
Enter
6
Because of your problem, do you feel frustrated?
*
This field is required.
2/10
Yes
Sometimes
No
Previous
Next
Submit
Press
Enter
7
Because of your problem, do you restrict your travel for business or recreation?
*
This field is required.
3/10
Yes
Sometimes
No
Previous
Next
Submit
Press
Enter
8
Does walking down the aisle of a supermarket increase your problems?
*
This field is required.
4/10
Yes
Sometimes
No
Previous
Next
Submit
Press
Enter
9
Because of your problem, do you have difficulty getting into or out of bed?
*
This field is required.
5/10
Yes
Sometimes
No
Previous
Next
Submit
Press
Enter
10
Because of your problem, are you afraid to leave your home without having without having someone accompany you?
*
This field is required.
6/10
Yes
Sometimes
No
Previous
Next
Submit
Press
Enter
11
Do quick movements of your head increase your problem?
*
This field is required.
7/10
Yes
Sometimes
No
Previous
Next
Submit
Press
Enter
12
.Because of your problem, is it difficult for you to concentrate?
*
This field is required.
8/10
Yes
Sometimes
No
Previous
Next
Submit
Press
Enter
13
Does turning over in bed increase your problem?
*
This field is required.
9/10
Yes
Sometimes
No
Previous
Next
Submit
Press
Enter
14
Because of your problem, are you depressed?
*
This field is required.
10/10
Yes
Sometimes
No
Previous
Next
Submit
Press
Enter
15
Dizzy Score
Click "Next" to see your results
Previous
Next
Submit
Press
Enter
16
Your results suggest mild dizziness. Even mild episodes can disrupt your daily routine. We can help you identify what’s triggering these symptoms and keep them from worsening.
Previous
Next
Submit
Press
Enter
17
Your results suggest moderate dizziness. This level of discomfort may be affecting your balance and quality of life more than you realize. Get personalized recommendations to address your dizziness before it progresses.
Your results suggest moderate dizziness. This level of discomfort may be affecting your balance and quality of life more than you realize. Get personalized recommendations to address your dizziness before it progresses. Call us or book an appointment today.
Previous
Next
Submit
Press
Enter
18
Your results indicate severe dizziness. Frequent or intense episodes can seriously impact your life. We’re here to help find immediate solutions and support. Get personalized recommendations to address your dizziness before it progresses.
Previous
Next
Submit
Press
Enter
19
Would you be interested to hear and talk about our services?
YES
NO
Previous
Next
Submit
Press
Enter
20
Preferred Contact Method
Call
Text
Email
Previous
Next
Submit
Press
Enter
21
When is the best time to reach you?
Morning
Afternoon
Evening
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
21
See All
Go Back
Submit