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. "*" indicates required fields Please answer the following questionsHave you fallen in the last 12 months?* Yes No 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?* Yes No Do you have a fear of falling?* Yes No 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?* Yes No 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?* Yes No 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?* Yes No 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?* Yes No 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?* Yes No Does bending over make you dizzy or off balance?* Yes No Do you sometimes have difficulty when getting up from a seated position?* Yes No Name* First Last Email* PhoneCAPTCHA 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.