Vestibular Rehabilitation Benefit questionnaire
This questionnaire asks about your dizziness on a typical day in the last week . Please do not include problems that you think are caused by another condition. Please answer all of the questions by selecting one of the answer options.
Your information
What is your full name?
* Required
What is your date of birth?
* Required
What is your postcode?
* Required
Part A - your symptoms
This section is about how often you experience different feelings.
I feel dizzy
* RequiredAll of the time Very often Quite often Sometimes Not very often Only very occasionally Never
I get a feeling of tingling, prickling or numbness in my body
* RequiredAll of the time Very often Quite often Sometimes Not very often Only very occasionally Never
I have a feeling that things are spinning or moving around
* RequiredAll of the time Very often Quite often Sometimes Not very often Only very occasionally Never
I feel as though my heart is pounding or fluttering
* RequiredAll of the time Very often Quite often Sometimes Not very often Only very occasionally Never
I feel unsteady, as though I may lose my balance
* RequiredAll of the time Very often Quite often Sometimes Not very often Only very occasionally Never
I have difficulty breathing or feel short of breath
* RequiredAll of the time Very often Quite often Sometimes Not very often Only very occasionally Never
Your dizziness
This section is about how dizzy you get when you move around. Please do not select ‘not at all dizzy’ if you avoid making the movement. You should either try the movement or talk to your balance therapist before answering.
Bending over makes me feel
* RequiredNot at all dizzy Very slightly Mildly dizzy Moderately dizzy Really quite dizzy Very dizzy Extremely dizzy
Lying down and/or turning over in bed makes me feel
* RequiredNot at all dizzy Very slightly dizzy Mildly dizzy Moderately dizzy Really quite dizzy Very dizzy Extremely dizzy
Looking up at the sky makes me feel
* RequiredNot at all dizzy Very dizzy Mildly dizzy Moderately dizzy Really quite dizzy Very dizzy Extremely dizzy
Moving my head slightly from side to side makes me feel
* RequiredNot at all dizzy Very slightly dizzy Mildly dizzy Moderately dizzy Really quite dizzy Very dizzy Extremely dizzy
Part B - how the dizziness is affecting you
Please read each question carefully. Some of the statements are phrased to suggest that you have difficulty, for example ‘I have trouble focusing my eyes’. Some are phrased to suggest you do not have difficulty, for example ‘I feel comfortable travelling’. If a question does not apply to you, please select ‘same as before’ rather than leaving it out.
Compared to before the dizziness, I feel comfortable travelling
* RequiredA lot more Quite a bit more A little bit more Same as before A little bit less Quite a bit less A lot less
Compared to before the dizziness, I feel confident
* RequiredA lot more Quite a bit more A little bit more Same as before A little bit less Quite a bit less A lot less
Compared to before the dizziness, I have difficulty looking after myself (for example, washing my hair, cleaning my teeth, dressing myself, etc)
* Required** None A lot more Quite a bit more A little bit more Same as before A little bit less Quite a bit less A lot less
Compared to before the dizziness, I feel comfortable going out alone
* RequiredA lot more Quite a bit more A little bit more Same as before A little bit less Quite a bit less A lot less
Compared to before the dizziness, I can concentrate and/or remember things
* RequiredA lot more Quite a bit more A little bit more Same as before A little bit less Quite a bit less A lot less
Compared to before the dizziness, I need to hold on to something for support
* RequiredA lot more Quite a bit more A little bit more Same as before A little bit less Quite a bit less A lot less
Compared to before the dizziness, I think my quality of life is good
* RequiredA lot more Quite a bit more A little bit more Same as before A little bit less Quite a bit less A lot less
Compared to before the dizziness, I avoid some activities, positions or situations
* Required** None A lot more Quite a bit more A little bit more Same as before A little bit less Quite a bit less A lot less
Compared to before the dizziness, I am happy to be on my own
* RequiredA lot more Quite a bit more A little bit more Same as before A little bit less Quite a bit less A lot less
Compared to before the dizziness, I feel stable in the dark or when my eyes are closed
* RequiredA lot more Quite a bit more A little bit more Same as before A little bit less Quite a bit less A lot less
Compared to before the dizziness, I take part in social activities
* Required** None A lot more Quite a bit more A little bit more Same as before A little bit less Quite a bit less A lot less
