How old were you when your problems started?
*
What symptoms did/do you have?
Is there any one time or place where your symptoms are at their worst (Please give details)?
Please answer the following questions using the responses in the drop down menu
Can you go out alone?
*
Often
Sometimes
Never
Do you have feelings that at times you will fall over?
*
Often
Sometimes
Never
Do you see things moving which you know cannot move i.e. buildings etc?
*
Often
Sometimes
Never
Do you ever feel that your eyes will not work properly at times i.e. they do not focus, play tricks on you?
*
Often
Sometimes
Never
Do you suffer from feelings of nausea?
*
Often
Sometimes
Never
Do you have feelings of dizziness?
*
Often
Sometimes
Never
Do you have feelings of dizziness when lying in bed?:
*
Often
Sometimes
Never
Do you suffer from migraine?
*
Often
Sometimes
Never
Do you feel that you have poor balance?
*
Often
Sometimes
Never
Do you feel you have poor coordination?
*
Often
Sometimes
Never
Are you very sensitive to bright lights?
*
Often
Sometimes
Never
Would you say you are more sensitive to sound than others?(Please give details)
Do you have problems in discriminating your lefts and rights?
*
Yes
No
When you are writing, do you find that after a time you begin to make silly mistakes, such as putting letters and/or words in the wrong order, or your ability to spell even simple words becomes difficult? (Please give details)
When you are very tired do you find that you know what you want to say but the words come out jumbled up?
*
Yes
No
When you are tired do you find that your coordination regresses and you bump into things or become clumsy? (Please give details)
Please use the space below to provide us with any more information that you feel may be of relevance
