Patient Self Quiz

Do you experience any of the following…?

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

If You Answered Yes to One or More of These Questions, a Vestibular and Equilibrium Evaluation Should Be Considered.