/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/questionnaires/,

/clinical/cckm-tools/content/questionnaires/name-104977-en.cckm

20170253

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Questionnaires

Dizziness Handicap Inventory (DHI) (PL300102 DT)

Dizziness Handicap Inventory (DHI) (PL300102 DT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #


PL300102-DT (Rev. 02/21/17) Worksheet Only – Not a Medical Record Document
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
DIZZINESS HANDICAP INVENTORY (DHI)



















Date: _____________________________
ANSWER EACH QUESTION AS IT PERTAINS TO YOUR DIZZINESS PROBLEM ONLY.




Only Check One Box Per Row
YES SOMETIMES NO
1. Does looking up increase your problem?
2. Because of your problem, do you feel frustrated?
3. Because of your problem, do you restrict your travel for business or
recreation?

4. Does walking down the aisle of a supermarket increase your problem?
5. Because of your problem, do you have difficulty getting into or out of bed?
6. Does your problem significantly restrict your participation in social activities
such as going out to dinner, going to the movies, dancing or to parties?

7. Because of your problem do you have difficulty reading?
8. Does performing more ambitious activities like sports, dancing, household
chores such as sweeping or putting dishes away increase your problem?

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

10. Because of your problem have you been embarrassed in front of others?
11. Do quick movements of your head increase your problem?
12. Because of your problem do you avoid heights?
13. Does turning over in bed increase your problem?
14. Because of your problem is it difficult for you to do strenuous housework or
yard work?

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

16. Because of your problem is it difficult for you to go for a walk by yourself?
17. Does walking down a sidewalk increase your problem?
18. Because of your problem is it difficult to concentrate?
19. Because of your problem is it difficult for you to walk around your house in the
dark?

20. Because of your problem are you afraid to stay home alone?
21. Because of your problem do you feel handicapped?
22. Has your problem placed stress on your relationships with members of your
family or friends?

23. Because of your problem are you depressed?
24. Does your problem interfere with your job or household responsibilities?
25. Does bending over increase your problem?

Total: ______________


Jacobson GP, Newman CW: The development of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg 1990;116: 424-427