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  1. Below each question, select the answer that best describes how you feel.
  2. The questions are broken up into three aspects: Physical, Emotional, and Functional

Questions

Does looking upward worsen your problem? (Aspect: Physical)
Do you feel frustrated because of your problem? (Aspect: Emotional)
Do you limit your business or leisure travels because of your problem? (Aspect: Functional)
Does walking through the corridor of a supermarket worsen your problem? (Aspect: Physical)
Do you find it difficult to lay down or get up from bed because of your problem? (Aspect: Functional)
Does your problem significantly restrict your participation in social activities? (Aspect: Functional)
Do you find it hard to read because of your problem? (Aspect: Functional)
Does your problem get worse when you perform more difficult activities such as, sports, dancing, indoor chores such as, sweeping and cleaning dishes? (Aspect: Physical)
Because of your problem, do you feel afraid of going out without someone who accompanies you? (Aspect: Emotional)
Because of your problem, do you feel ashamed about the presence of other people? (Aspect: Emotional)
Do quick movements of your head worsen your problems? (Aspect: Physical)
Due to your problem, do you avoid high places? (Aspect: Functional)
Does turning in bed worsen your problem? (Aspect: Physical)
Because of your problem, is it difficult for you to do indoor or outdoor chores? (Aspect: Functional)
Because of your problem, do you fear that people think you are drugged or drunk? (Aspect: Emotional)
Because of your problem, is it difficult for you to get out for a walk without help? (Aspect: Functional)
Does walking on the sidewalk worsen your problem? (Aspect: Physical)
Because of your problem, is it difficult for you to concentrate? (Aspect: Emotional)
Because of your problem, is it difficult for you to walk into your house in the dark? (Aspect: Functional)
Due to your problem, do you fear staying home alone? (Aspect: Emotional)
Due to your problem, do you feel disabled? (Aspect: Emotional)
Does your problem damage your relationship with your relatives or friends? (Aspect: Emotional)
Due to your problem, are you depressed? (Aspect: Emotional)
Does your problem interfere with your work or duties at home? (Aspect: Functional)
Does becoming inclined worsen our problem? (Aspect: Physical)
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