| Does looking up increase your problem? | | | |
| Because of your problem, do you feel frustrated? | | | |
| Because of your problem, do you restrict your travel for business or recreation? | | | |
| Does walking down the aisle of a supermarket increase your problems? | | | |
| Because of your problem, do you have difficulty getting into or out of bed? | | | |
| Does your problem significantly restrict your participation in social activities, such as going out to dinner, going to the movies, dancing, or going to parties? | | | |
| Because of your problem, do you have difficulty reading? | | | |
| Does performing more ambitious activities such as sports, dancing, household chores (sweeping or putting dishes away) increase your problems? | | | |
| Because of your problem, are you afraid to leave your home without having without having someone accompany you? | | | |
| Because of your problem have you been embarrassed in front of others? | | | |
| Do quick movements of your head increase your problem? | | | |
| Because of your problem, do you avoid heights? | | | |
| Does turning over in bed increase your problem? | | | |
| Because of your problem, is it difficult for you to do strenuous homework or yard work? | | | |
| Because of your problem, are you afraid people may think you are intoxicated? | | | |
| Because of your problem, is it difficult for you to go for a walk by yourself? | | | |
| Does walking down a sidewalk increase your problem? | | | |
| Because of your problem, is it difficult for you to concentrate | | | |
| Because of your problem, is it difficult for you to walk around your house in the dark? | | | |
| Because of your problem, are you afraid to stay home alone? | | | |
| Because of your problem, do you feel handicapped? | | | |
| Has the problem placed stress on your relationships with members of your family or friends? | | | |
| Because of your problem, are you depressed? | | | |
| Does your problem interfere with your job or household responsibilities? | | | |
| Does bending over increase your problem? | | | |
