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How long have you had symptoms of Dizziness/Imbalance?
1-7 Days
8-30 Days
1-3 Months
3-6 Months
6 Months or More
Have you curtailed your daily activities due to your dizziness ?
Lots
Sometimes
No
Have your symptoms improved or gotten worse since they started ?
Got Worse
Got Better
Out of 100, what percent of the day do you have symptoms ?
Can you rate your dizziness out of 10 today ( 0 is no Dizziness)
1
2
3
4
5
6
7
8
9
10
How much do you want to get better on a scale of 1- 10 ?
1
2
3
4
5
6
7
8
9
10
Has your Dr/Therapist/Friend Let You Know The Benefits of Vestibular Rehabilitation
Yes
No
Have you been diagnosed previously? With what?
No Diagnosis
BBPV
Vestibular Neuritis
Vestibular Fatigue
PPPD
Vestibular Migraine
Labyrinthitis
Meniere's Disease
Told whatever it is you have to live with it
Questions that Indicate you have BBPV
Does looking up increase your problem ?
Yes
No
Sometimes
Does turning over in bed increase your problem ?
Yes
No
Sometimes
Does bending over increase your problem ?
Yes
No
Sometimes
Questions that Indicate you have Vestibular Neuritis
Did your Dizziness Start With ONE, sudden, severe attack of Vertigo, Imbalance & Nausea?
Yes
No
Do you lose focus when moving your head ?
Yes
No
Sometimes
PPPD Questions
Do you have difficulty reading while moving ?
Yes
No
Do you suffer from anxiety?
Yes
No
Sometimes
Do you feel worse while in motion?
Yes
No
Sometimes
Does going to the Supermarket increase your Dizziness?
Yes
No
Questions that Indicate you have Vestibular Migraine
Does looking at Venetian Blinds / Stripes Provoke your Dizziness ?
Yes
No
Did you get car sickness on short car journeys, as a child ?
Yes
No
Are you sensitive to bright lights ?
Yes
No
Questions that Indicate you have Meniere's
Have you had MULTIPLE, Sudden, Severe, attacks of Vertigo/Dizziness lasting 3-72hrs? Over MORE than 3 months
Yes
No
Do you get hearing loss & Tinnitus (Ringing in the Ears) with your Vertigo attacks?
Yes
No
Let us know your No. If you would like a free call to chat about your results,
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