Dizziness Handicap Inventory – MIPS – Progressive Physical Therapy

INSTRUCTIONS: The purpose of this scale is to identify difficulties that you may be experiencing because of your dizziness. Please check “always”, or “no” or “sometimes” to each question. Answer each question only as it pertains to your dizziness problem.

ALL QUESTIONS MUST BE ANSWERED

Name *

First

Middle

Last

Date / Time

1. Does looking up increase your problem? *

Yes
Sometimes
No

2. Because of your problem, do you feel frustrated? *

Yes
Sometimes
No

3. Because of your problem, do you restrict your travel for business or pleasure? *

Yes
Sometimes
No

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

Yes
Sometimes
No

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

Yes
Sometimes
No

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

Yes
Sometimes
No

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

Yes
Sometimes
No

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

Yes
Sometimes
No

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

Yes
Sometimes
No

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

Yes
Sometimes
No

11. Do quick movements of your head increase your problem? *

Yes
Sometimes
No

12. Because of your problem, do you avoid heights? *

Yes
Sometimes
No

13. Does turning over in bed increase your problem? *

Yes
Sometimes
No

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

Yes
Sometimes
No

15. Because of your problem, are you afraid people may think that you are intoxicated? *

Yes
Sometimes
No

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

Yes
Sometimes
No

17. Does walking down a sidewalk increase your problem? *

Yes
Sometimes
No

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

Yes
Sometimes
No

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

Yes
Sometimes
No

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

Yes
Sometimes
No

21. Because of your problem, do you feel handicapped? *

Yes
Sometimes
No

22. Has your problem placed stress on your relationship with members of your family or friends? *

Yes
Sometimes
No

23. Because of your problem, are you depressed? *

Yes
Sometimes
No

24. Does your problem interfere with your job or household responsibilities? *

Yes
Sometimes
No

25. Does bending over increase your problem? *

Yes
Sometimes
No

26. Pain Score: How would you rate your pain over the past 24 hours?

Selected Value: 0