I fell or almost fell within the past year.
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Yes No
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I am afraid that I will fall.
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Yes No
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I get short of breath when I walk.
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Yes No
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I have pain when I walk.
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Yes No
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I use a cane or walker.
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Yes No
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I take pills for sleep, depression, or anxiety.
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Yes No
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I take pills for high blood pressure.
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Yes No
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I have broken my hip.
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Yes No
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I have tremors or Parkinson's disease.
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Yes No
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I have had a stroke.
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Yes No
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When I quickly move my head or roll over in bed, I
feel dizzy or out of balance.
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Yes No
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Moving from a sitting to a standing position makes me
dizzy or lightheaded.
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Yes No
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I walk funny or feel like I am still moving after
being in the car, train, plane, or elevator.
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Yes No
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Loud noises throw off my balance.
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Yes No
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I get dizzy or lightheaded after exercising or
straining.
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Yes No
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Eating or drinking certain foods may effect my
balance.
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Yes No
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I get dizzy when changing my focus from up close to
looking far away like reading and then watching TV, or the opposite.
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Yes No
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I feel unbalanced or dizzy because I have difficulty
in judging distances when I walk, drive or am active.
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Yes No
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I lose my balance or feel like I'm going to fall when
I go up or down stairs.
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Yes No
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I seem to bump into things more than I used to.
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Yes No
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I experience dizziness and sudden loss of vision in
one or both eyes that lasts more than 5 minutes.
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Yes No
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I sometimes feel disoriented and see flashing lights
and spots.
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Yes No
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My vision gets wavy and I feel like I should sit down.
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Yes No
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I have double vision that lasts for more than one
minute.
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Yes No
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