Full Name
*
First Name
Middle Name
Last Name
DOB
*
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Month
-
Day
Year
Date
Today's Date
*
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Month
-
Day
Year
Date
The Dizziness Handicap Inventory ( DHI )
Does looking up increase your problem?
*
Yes
Sometimes
No
Because of your problem, do you feel frustrated?
*
Yes
Sometimes
No
Because of your problem, do you restrict your travel for business or recreation?
*
Yes
Sometimes
No
Does walking down the aisle of a supermarket increase your problems?
*
Yes
Sometimes
No
Because of your problem, do you have difficulty getting into or out of bed?
*
Yes
Sometimes
No
Does your problem significantly restrict your participation in social activities, such as going out to dinner, going to the movies, dancing, or going to parties?
*
Yes
Sometimes
No
Because of your problem, do you have difficulty reading?
*
Yes
Sometimes
No
Does performing more ambitious activities such as sports, dancing, household chores (sweeping or putting dishes away) increase your problems?
*
Yes
Sometimes
No
Because of your problem, are you afraid to leave your home without having without having someone accompany you?
*
Yes
Sometimes
No
Because of your problem have you been embarrassed in front of others?
*
Yes
Sometimes
No
Do quick movements of your head increase your problem?
*
Yes
Sometimes
No
Because of your problem, do you avoid heights?
*
Yes
Sometimes
No
Does turning over in bed increase your problem?
*
Yes
Sometimes
No
Because of your problem, is it difficult for you to do strenuous homework or yard work?
*
Yes
Sometimes
No
Because of your problem, are you afraid people may think you are intoxicated?
*
Yes
Sometimes
No
Because of your problem, is it difficult for you to go for a walk by yourself?
*
Yes
Sometimes
No
Does walking down a sidewalk increase your problem?
*
Yes
Sometimes
No
Because of your problem, is it difficult for you to concentrate?
*
Yes
Sometimes
No
Because of your problem, is it difficult for you to walk around your house in the dark?
*
Yes
Sometimes
No
Because of your problem, are you afraid to stay home alone?
*
Yes
Sometimes
No
Because of your problem, are you afraid to stay home alone?
*
Yes
Sometimes
No
Because of your problem, do you feel handicapped?
*
Yes
Sometimes
No
Has the problem placed stress on your relationships with members of your family or friends?
*
Yes
Sometimes
No
Because of your problem, are you depressed?
*
Yes
Sometimes
No
Does your problem interfere with your job or household responsibilities?
*
Yes
Sometimes
No
Does bending over increase your problem?
*
Yes
Sometimes
No
Thanks for taking the time to fill out the form!
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