AAA PT DIZZINESS HANDICAP INVENTORY

AAA PT DIZZINESS HANDICAP INVENTORY
Patients Name:*

First NameLast Name
Date*

MonthDayYear
Date
Instructions: The purpose of this scale is to identify difficulties that you may be experiencing because of your dizziness and unsteadiness. Please indicate answer by clicking “yes”, or “no” or “sometimes” for each question. Answer each question as it pertains to your dizziness or unsteadiness problems only.
1. Does looking up increase your problem? (P)*

YesNoSometimes
2. Because of your problem, do you feel frustrated? (E)*

YesNoSometimes
3. Because of your problem, do you restrict your travel for business or recreation? (F)*

YesNoSometimes
4. Does walking down the aisle of a supermarket increase your problem? (P)*

YesNoSometimes
5. Because of your problem, do you have difficulty getting into or out of bed? (F)*

YesNoSometimes
6. Does your problem significantly restrict your participation in social activities such as going out to dinner, going to the movies, dancing, or to parties? (F)*

YesNoSometimes
8. Does performing more ambitious activities like sports, dancing, household such as sweeping or putting away dishes increase your problem? (P)*

YesNoSometimes
9. Because of your problem, are you afraid to leave your home without having someone accompany you? (E)*

YesNoSometimes
10. Because of your problem, have you been embarrassed in front of others? (E)*

YesNoSometimes
11. Do quick movements of your head increase your problem? (P)*

YesNoSometimes
12. Because of your problem, do you avoid heights? (F)*

YesNoSometimes
13. Does turning over in bed increase your problem? (P)*

YesNoSometimes
14. Because of your problem, is it difficult for you to do strenuous housework or yard work? (F)*

YesNoSometimes
15. Because of your problem, are you afraid people might think you are intoxicated? (E)*

YesNoSometimes
16. Because of your problem, is it difficult for you to go for a walk by yourself? (F)*

YesNoSometimes
17. Does walking down a sidewalk increase your problem? (P)*

YesNoSometimes
Date*

MonthDayYear
Date
Patient Signature*

Clear
Please affix your signature inside the box

p. 443.979.7171

AAA Physical Therapy, LLC
admin@AAAPhysicalTherapy.com
8975 Guilford Rd Ste 170 Columbia, MD 21046

f. 667.200.5908

Should be Empty: