Do the Test – BalanceBelt

1. Do you use walking aids?

(Select one or more)

Crutches

Cane

Walker frame

Rollator

Wheel chair

I do not use walking aids

2. How many times did you fall in the last 6 months?

I did not fall

I fell 1 - 2 times

I fell 3 times or more

3. Can you stand and/or walk when somebody holds your hand?

No

I can stand

I can stand and walk

4. How would you rate your Balance and Mobility?

Rate your balance and mobility on a 1-10 scale; 1 = cannot stand/walk without aids. 10 = before your balance problems started

5. How is your vision? (tick the boxes)

I have blurred vision while walking.

I have blurred vision while travelling (train, car, etc.)

When walking, I have to stand still to recognise faces or to read (road) signs.

I have blurred vision while chewing on my food.

I have blurred vision when quickly turning my head.

None of the above

6. How is your Balance? Do you experience balance problems when:

turning your head to the right or left when crossing the street

walking on uneven surfaces (like in the woods, beach, etc.)

during daily activities

walking in reduced light

When walking, I need to pay attention to the ground to avoid falling.

None of the above

7. Do you have a diagnosed condition?

Bilateral Vestibular Hypofunction or Loss (BVH or BVL)

Unilateral Vestibular Hypofunction or Loss (UVH or UVL)

Persistent Postural-Perceptual Dizziness (PPPD)

I had a stroke

A neurologic conditions (MS, Parkinson, etc.)

None of the above

What neurlogic condition do you have?

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BalanceBelt Test

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