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The Dizziness Handicap Inventory (DHI)
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* Indicates required question
Full Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Today’s Date
*
MM
/
DD
/
YYYY
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 problems?
*
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 the movies, dancing, or going to parties?
*
Yes
Sometimes
No
7. Because of your problem, do you have difficulty reading?
*
Yes
Sometimes
No
8. Does performing more ambitious activities such as sports, dancing, household chores (sweeping or putting dishes away) increase your problems?
*
Yes
Sometimes
No
9. Because of your problem, are you afraid to leave your home without having 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 homework or yard work?
*
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 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 the problem placed stress on your relationships 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
Used with permission from GP Jacobson. Jacobson GP, Newman CW: The development of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg1990;116: 424-427
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