Center for Balance Cincinnati | Dizziness and Fall Risk Questionnaire

Do you suffer from dizziness/vertigo, or feel you are you at risk of falling?

There is help for your symptoms!

Answer the questions below to receive a free report regarding your symptoms.

Enter your name and email address to receive your results.

Dr Shumrick personally reviews all submissions and responds to you via email

Disclaimer: This should not be used as a diagnostic tool but as an educational tool for consideration of assessment and treatment. These questions are based on actual patient dizziness and balance complaints and symptoms common in our clinics. Dizziness, vertigo, and balance problems are not identified or helped by simple testing (MRIs, etc) or medications. Rather, a full functional assessment is required to identify your problems so an individualized treatment plan can be created and tailored to meet your specific needs.

Please answer the following questions.

Have you fallen in the last 12 months? Have you fallen in the last 12 months?: yes no

Do you take four or more prescription medications daily? Do you take four or more prescription medications daily?: yes no

Because of your problem, is it difficult for you to go for a walk by yourself? Because of your problem, is it difficult for you to go for a walk by yourself?: yes no

Do you have a fear of falling? Do you have a fear of falling?: yes no

Does looking up/titling your head back make you dizzy or off balance? Does looking up/titling your head back make you dizzy or off balance?: yes no

Does walking down the aisle of a supermarket without a cart increase your dizziness or imbalance? Does walking down the aisle of a supermarket without a cart increase your dizziness or imbalance?: yes no

Do you have trouble getting into or out of bed? Do you have trouble getting into or out of bed?: yes no

Do you restrict your participation in social activities such as going out to dinner, movies, dancing, or parties? Do you restrict your participation in social activities such as going out to dinner, movies, dancing, or parties?: yes no

Are you afraid to leave your home without having someone accompany you? Are you afraid to leave your home without having someone accompany you?: yes no

Do quick movements of your head make you dizzy or off balance? Do quick movements of your head make you dizzy or off balance?: yes no

Does rolling onto your side in bed make you dizzy? Does rolling onto your side in bed make you dizzy?: yes no

Is it difficult for you to walk around your house in the dark? Is it difficult for you to walk around your house in the dark?: yes no

Are you afraid to stay home alone? Are you afraid to stay home alone?: yes no

Have your dizziness or balance problems placed stress on relationships with members of your family or friends? Have your dizziness or balance problems placed stress on relationships with members of your family or friends?: yes no

Does bending over make you dizzy or off balance? Does bending over make you dizzy or off balance?: yes no

Do you sometimes have difficulty when getting up from a seated position? Do you sometimes have difficulty when getting up from a seated position?: yes no

Your name: Your name:

Your email address: Your email address