Your Name
Your Email address
Your Phone Nos.
Name of the medicines that you were last prescribed by Dr. Biswas
How is your condition now after treatment
Select your choice---
Same
Better
Worse
Write about your present condition within 50 words
Answer the following questions:-
Does looking up increase your problem?
Select your choice ---
Yes
Sometimes
No
Because of your problem, do you feel frustrated?
Select your choice ---
Yes
Sometimes
No
Because of your problem, do you restrict your travel for business or recreation?
Select your choice ---
Yes
Sometimes
No
Does walking down the aisle of a supermarket increase your problem?
Select your choice ---
Yes
Sometimes
No
Because of your problem, do you have difficulty getting into or out of bed?
Select your choice ---
Yes
Sometimes
No
Does your problem significantly restrict your participation in social activities such as going out to dinner,going to movies or to parties?
Select your choice ---
Yes
Sometimes
No
Because of your problem, do you have difficulty in reading?
Select your choice ---
Yes
Sometimes
No
Does performing more ambitious activities like sports, dancing, household chores such as sweeping or putting dishes away increase your problem?
Select your choice ---
Yes
Sometimes
No
Because of your problem, are you afraid to leave your home without having some one accompany you?
Select your choice ---
Yes
Sometimes
No
Because of your problem, have you been embarrassed in front of others?
Select your choice ---
Yes
Sometimes
No
Do quick movements of your head increase your problem?
Select your choice ---
Yes
Sometimes
No
Because of your problem, do you avoid heights?
Select your choice ---
Yes
Sometimes
No
Does turning over in bed increase your problem?
Select your choice ---
Yes
Sometimes
No
Because of your problem, is it difficult for you to do strenuous housework or yardwork?
Select your choice ---
Yes
Sometimes
No
Because of your problem, are you afraid people may think you are intoxicated?
Select your choice ---
Yes
Sometimes
No
Because of your problem, is it difficult for you to walk by yourself?
Select your choice ---
Yes
Sometimes
No
Does walking down a sidewalk increase your problem?
Select your choice ---
Yes
Sometimes
No
Because of your problem, is it difficult for you to concentrate?
Select your choice ---
Yes
Sometimes
No
Because of your problem, is it difficult for you to walk around your house in the dark?
Select your choice ---
Yes
Sometimes
No
Because of your problem, are you afraid to stay at home alone?
Select your choice ---
Yes
Sometimes
No
Because of your problem, do you feel handicapped?
Select your choice ---
Yes
Sometimes
No
Has your problem placed stress on your relationships with members of your family or friends?
Select your choice ---
Yes
Sometimes
No
Because of your problem, are you depressed?
Select your choice ---
Yes
Sometimes
No
Does your problem interfere with your job or household responsibilities?
Select your choice ---
Yes
Sometimes
No
Does bending over increase your problem?
Select your choice ---
Yes
Sometimes
No
Do you have a persistant imbalance?
Select your choice ---
Yes
Sometimes
No
Do you get severe spells of vertigo with nausee/vomiting now?
Select your choice ---
Yes
Sometimes
No
Do you feel very drowsy?
Select your choice ---
Yes
Sometimes
No
Do you have any headache?
Select your choice ---
Yes
Sometimes
No
Do you have any weakness or loss of sensation/some part of the body?
Select your choice ---
Yes
Sometimes
No
Do you have double vision?
Select your choice ---
Yes
Sometimes
No
