| 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 recreation? |
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, 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 home without having someone with 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 yardwork? |
Yes |
Sometimes |
No |
| 15. |
Because of your problem, are you afraid people may think 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 go for a 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 |
