*1. Does looking up increase your problem?
*2. Because of your problem, do you feel frustrated?
*3. Because of your problem, do you restrict your travel for business or recreation?
*4. Does walking down the aisle of a supermarket increase your problems?
*5. Because of your problem, do you have difficulty getting into or out of bed?
*6. 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?
*7. Because of your problem, do you have difficulty reading?
*8. Does performing more ambitious activities such as sports, dancing, household chores (sweeping or putting dishes away) increase your problems?
*9. Because of your problem, are you afraid to leave your home without having without having someone accompany you?
*10. Because of your problem have you been embarrassed in front of others?
*11. Do quick movements of your head increase your problem?
*12. Because of your problem, do you avoid heights?
*13. Does turning over in bed increase your problem?
*14. Because of your problem, is it difficult for you to do strenuous homework or yard work?
*15. Because of your problem, are you afraid people may think you are intoxicated?
*16. Because of your problem, is it difficult for you to go for a walk by yourself?
*17. Does walking down a sidewalk increase your problem?
*18. Because of your problem, is it difficult for you to concentrate?
*19. Because of your problem, is it difficult for you to walk around your house in the dark?
*20. Because of your problem, are you afraid to stay home alone?
*21. Because of your problem, do you feel handicapped?
*22. Has the problem placed stress on your relationships with members of your family or friends?
*23. Because of your problem, are you depressed?
*24. Does your problem interfere with your job or household responsibilities?
*25. Does bending over increase your problem?