Patient Self Quiz for Dizziness & Balance Problems

1. A feeling of motion, spinning or falling when moving your head quickly or changing your position? (Ex. Getting in and out of bed) Yes No
2. Uncomfortable trying to get around in the dark? Yes No
3. Walking down the grocery store aisles or through the mall is upsetting? Yes No
4. Your feet just won't go where you want them to? Yes No
5. A sense of unsteadiness? A feeling you are not surefooted? Yes No
6. A fear of falling or stumbling? Yes No
7. Looking at moving objects such as escalators or looking out the side window of a car makes you queasy? Yes No
8. Difficulty keeping your balance as you walk on different surfaces? (Ex. Tile to carpet) Yes No
9. A feeling like you are drifting or being pulled to one side when walking? Yes No
10. No one really understands how frustrating this is? Yes No