Alaska Dizziness and Balance Centers

Please print this page and attach a copy to your new patient form.
Have you fallen more than once in the last year?	Yes No
Do you take medications for two or more of the following heart disease, hyper tension, arthritis, anxiety or depression?	Yes No
Do you need to climb a flight or more of steps each day?	Yes No
Do you have dizziness or balance problems frequently?	Yes No
Do you have blackouts or seizures?	Yes No
Do you sometimes take unnecessary risks?	Yes No
Have you experienced a stroke or other neurological problem that has affected your balance?	Yes No
Do you experience a numbness or loss of sensation in your legs and/or feet?	Yes No
Do you use a walker or wheelchair, or do you need assistance to get around?	Yes No
Do you participate in a regular activity, such as walking or exercising for 20-30 minutes at least three times a week?	Yes No
Do you feel unsteady when you are walking?	Yes No

If you have answered yes to one or more of the questions above, you may have a dizziness or balance problem. Click here for our patient's resources page.