Vestibular and Postural Assessment Quiz
Please complete this quiz to help us evaluate your balance and postural health. Your responses will assist in identifying any vestibular or postural concerns.
Full Name
*
First Name
Last Name
Age
*
Have you experienced any of the following symptoms recently? (Select all that apply)
*
Dizziness or vertigo
Unsteadiness while standing or walking
Frequent falls or near-falls
Nausea related to movement
Blurred vision during head movement
None of the above
Other
Do you have a history of any of the following conditions? (Select all that apply)
*
Inner ear infections
Head injuries or concussions
Neurological disorders
Balance disorders
None of the above
Other
How would you rate your balance while standing still?
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
Do you use any assistive devices for walking or standing?
*
No assistive devices
Cane
Walker
Wheelchair
Other
Please describe any additional concerns or symptoms related to your balance or posture.
Submit Assessment
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