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Discover Your Dizziness Severity in Under 2 Minutes
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18
Questions
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HIPAA
Compliance
1
Name
*
This field is required.
First Name
Last Name
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2
Phone Number
*
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Please enter a valid phone number.
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3
Email
*
This field is required.
example@example.com
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4
I have...
Dizziness
Tinnitus
Vertigo
Hearing Loss
Imbalance
Headache
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5
Does looking up increase your problem?
*
This field is required.
1/10
Yes
Sometimes
No
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6
Because of your problem, do you feel frustrated?
*
This field is required.
2/10
Yes
Sometimes
No
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7
Because of your problem, do you restrict your travel for business or recreation?
*
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3/10
Yes
Sometimes
No
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8
Does walking down the aisle of a supermarket increase your problems?
*
This field is required.
4/10
Yes
Sometimes
No
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9
Because of your problem, do you have difficulty getting into or out of bed?
*
This field is required.
5/10
Yes
Sometimes
No
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10
Because of your problem, are you afraid to leave your home without having without having someone accompany you?
*
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6/10
Yes
Sometimes
No
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11
Do quick movements of your head increase your problem?
*
This field is required.
7/10
Yes
Sometimes
No
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12
.Because of your problem, is it difficult for you to concentrate?
*
This field is required.
8/10
Yes
Sometimes
No
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13
Does turning over in bed increase your problem?
*
This field is required.
9/10
Yes
Sometimes
No
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14
Because of your problem, are you depressed?
*
This field is required.
10/10
Yes
Sometimes
No
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15
Dizzy Score
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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.
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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.
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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.
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19
If there was a non-invasive, supportive way to improve your balance or dizziness problems would you want to learn more?
*
This field is required.
Yes, definitely
I'd like more information
I'm not sure, but I'm open to it
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20
What concerns or questions do you have about your symptoms or treatment options?
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21
Preferred Contact Method
*
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Call
Text
Email
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