Because of dizziness or imbalance, have you become unable to carry out household responsibilities (such as cleaning, cooking)?

Because of dizziness or imbalance, do you feel tired or confused while reading or watching television?

Because of dizziness or imbalance, do you no longer enjoy recreational activities such as walking, gardening or sport?

Because of dizziness or imbalance, is it difficult for you to turn over in bed or get up?

Because of dizziness or imbalance, do you feel limited in making short trips?

Because of dizziness or imbalance, do you have trouble reading a newspaper or book?

Have vigorous activities such as sport, dancing or heavy work become limited for you because of dizziness?

Because of dizziness or imbalance, do you avoid crowded places for fear of falling?

Because of dizziness or imbalance, do you feel unsafe in dark places or when walking on a carpet?

Because of dizziness or imbalance, do you avoid long trips by car or bus?

Because of dizziness or imbalance, do you have trouble walking in shop aisles or public places?

Because of dizziness or imbalance, do you feel uncomfortable performing fine tasks (such as writing or sewing)?

Because of dizziness or imbalance, have you become dependent on others for daily activities?

Because of dizziness or imbalance, do you avoid parties or family gatherings?

Because of dizziness or imbalance, do you feel afraid while walking on uneven surfaces (such as grass or gravel)?

Because of dizziness or imbalance, do you feel unsafe in high places (such as stairs or a balcony)?

Because of dizziness or imbalance, do you avoid sudden movements (such as turning your head quickly)?

Have dizziness or imbalance made you lose your self-confidence in company?

Because of dizziness or imbalance, are you afraid to leave your home alone?

Have dizziness or imbalance made you feel disabled or handicapped?

Have dizziness or imbalance affected your marital or close relationships?

Because of dizziness or imbalance, do you avoid tasks that require high concentration (such as driving)?

Have dizziness or imbalance caused you problems at work or school?

Because of dizziness or imbalance, do you feel that you have no normal life?