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

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