Chapman Dizziness survey

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Dizziness/Vertigo Pre-Exam Form
Chapman Location

For any patient experiencing a form of dizziness or vertigo, please fill out to the best of your ability and submit.

* Indicates required field

Name *

First

Last

PLEASE RATE YOUR PAIN LEVEL WITH ACTIVITY *

0 - No Pain 1 - Minimal - hardly noticeable 2-Mild - aware of pain but don't pay attention to it 3-Uncomfortable - bothers me but I can ignore it 4-Moderate - Constantly aware but can continue most activities 5-Distracting - Constantly aware and keeping me from doing some activities 6 - Distressing - Constantly aware of pain and I give up many activities. 7-Unmanageable - In pain all the time and unable to do most activities 8-Intense - Pain is so severe that it is hard to think of anything else. Talking & listening are difficult 9-Severe - My pain is all I can think about. I can barely talk or move because of it. 10-Unable to Move - In bed and can't move due to my pain. I need to go to the emergency room.

The purpose of this scale is to identify difficulties that you may be experiencing because of your dizziness or unsteadiness. Please indicate your answer by marking "yes" or "no" or "sometimes" for each questions. Answer each question as it pertains to your dizziness problem only.

Does looking up increase your problem? *

Yes No Sometimes

Because of your problem, do you feel frustrated? *

Yes No Sometimes

Because of your problem, do you restrict your travel for business or recreation? *

Yes No Sometimes

Does walking down the aisle of a supermarket increase your problem? *

Yes No Sometimes

Because of your problem, do you have difficulty getting into or out of bed? *

Yes No Sometimes

Does your problem significantly restrict your participation in social activities such as going out to dinner, going to the movies, dancing, or to parties? *

Yes No Sometimes

Because of your problem, do you have difficulty reading? *

Yes No Sometimes

Does performing more ambitious activities like sports, dancing, household chores such as sweeping or putting away dishes increase your problem? *

Yes No Sometimes

Because of your problem, are you afraid to leave your home without having someone accompany you? *

Yes No Sometimes

Because of your problem, have you been embarrassed in front of others? *

Yes No Sometimes

Do quick movements of your head increase your problem? *

Yes No Sometimes

Because of your problem, do you avoid heights? *

Yes No Sometimes

Does turning over in bed increase your problem? *

Yes No Sometimes

Because of your problem, is it difficult for you to do strenuous housework or yard work? *

Yes No Sometimes

Because of your problem, are you afraid people might think you are intoxicated? *

Yes No Sometimes

Because of your problem, is it difficult for you to go for a walk by yourself? *

Yes No Sometimes

Does walking down a sidewalk increase your problem? *

Yes No Sometimes

Because of your problem, is it difficult for you to concentrate? *

Yes No Sometimes

Because of your problem, is it difficult for you to walk around the house in the dark? *

Yes No Sometimes

Because of your problem, are you afraid to stay home alone? *

Yes No Sometimes

Because of your problem, do you feel handicapped? *

Yes No Sometimes

Has your problem placed stress on your relationships with members of your family or friends? *

Yes No Sometimes

Because of your problem, are you depressed? *

Yes No Sometimes

Does your problem interfere with you job or household responsibilities? *

Yes No Sometimes

Does bending over increase your problem? *

Yes No Sometimes

Choose the option that best describes you: *

Negligible symptoms Bothersome symptoms Performs usual work duties but symptoms interfere with outside activities Symptoms disrupt performance of both usual work duties and outside activities Unable to work for over one year or established permanent disability with compensation payments

Submit

The state of Kansas is a “Direct Access” state for Physical Therapy.
You can begin physical therapy with or without a referral from a physician.

Now with 2 Locations to Better Serve You!

ABILENE:
103 Northwest 15th Street
Abilene, KS 67410
Phone: 785-263-3646
FAX: 785-263-3689

HOURS:
Monday - Friday
8 a.m. - 5 p.m.

CHAPMAN:
1030 North Marshall, Suite B
Chapman, KS 67431
Phone: 785-922-4016
FAX: 785-922-4018

HOURS:
Monday - Friday
8 a.m. - 5 p.m.

The purpose of this scale is to identify difficulties that you may be experiencing because of your dizziness or unsteadiness. Please indicate your answer by marking "yes" or "no" or "sometimes" for each questions. Answer each question as it pertains to your dizziness problem only.

The state of Kansas is a “Direct Access” state for Physical Therapy. ​ You can begin physical therapy with or without a referral from a physician. ​

The state of Kansas is a “Direct Access” state for Physical Therapy.
You can begin physical therapy with or without a referral from a physician.