| Regarding my current state of overall function, not just during attacks (check the ONE that best applies): | |
| 1. My dizziness has no effect on my activities at all. | |
| 2. When I am dizzy I have to stop what I am doing for a while, but it soon passes and I can resume activities. I continue to work, drive, and engage in any activity I choose without restriction. I have not changed any plans or activities to accommodate my dizziness. | |
| 3. When I am dizzy I have to stop what I am doing for a while, but it does pass and I can resume activities. I continue to work, drive, and engage in most activities I choose, but I have had to change some plans and make some allowance for my dizziness. | |
| 4. I am able to work, drive, travel, take care of a family, or engage in most essential activities, but I must exert a great deal of effort to do so. I must constantly make adjustments in my activities and budget my energies. I am barely making it. | |
| 5. I am unable to work, drive, or take care of a family. I am unable to do most of the active things that I used to. Even essential activities must be limited. I am disabled. | |
| 6. I have been disabled for one year or longer and/or I receive compensation (money) because of my dizziness or balance problem. | |
