The following TWO questionnaires are for completion by those who have been referred to our Audiology Department’s Balance Rehabilitation Service.

It is important that you answer both questionnaires. Once you have pressed 'submit' for the 'Vestibular Rehab Benefit' form there is another form below named 'H.A.D.S Questionnaire' that should also be completed. 

Please complete the questionnaires BEFORE each appointment, so that there is enough time in the appointment to discuss your needs and to start your vestibular rehabilitation programme.

If you have any difficulty completing the questionnaires, or would like to request them in paper format instead, please contact our Audiology Department on 0191 569 9001, or at stsft.audiology@nhs.net.

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 circling one of the answer options.

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Part A – your symptoms

This section is about how often you experience different feelings

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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 - either try the movement or talk to your balance therapist before answering.

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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’) and 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.

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H.A.D.S. Questionnaire

Please read each item below and choose the reply that comes closest to how you have been feeling in the past week.

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Questions

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We cannot guarantee the information submitted in this form will be transferred securely to the Trust and you submit this at your own risk.

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