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Do you have a feeling of motion, spinning or falling when moving your head quickly or changing your position? (For example, getting in and out of bed.) YesNo
Do you have difficulty getting around and maintaining your balance in the dark? YesNo
Do you find it disorienting or upsetting when you have to walk through grocery store aisles or the mall? YesNo
Do your feet sometimes just not go where you want them to? YesNo
Do you have a general sense of unsteadiness, or that your are not surefooted when you move around? YesNo
Do you have a fear of falling or stumbling? YesNo
Do you have difficulty maintaining your balance as you walk on different surfaces? For example: moving from a tiled to a carpeted surface. YesNo
Do you a feeling that you are drifting or being pulled to one side as you are walking? YesNo
Do you experience difficulty in explaining to others how difficult this is? (We can help!) YesNo
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