2. What part of the world did you have your car accident?

    Click Here USA Africa Asia Austrailia/New Zealand Canada Central America Eastern Europe Europe Mexico South America Other

3. How old are you?                        

    Click Here Under 18 19-30 30-40 40-50 50-65 65+         

    What is your gender?

    Click here Male Female

4. How did your car get hit?

Front-Head On
Front Quarter Panel-NOT Head On
Driver's Side
Passenger's Side
Rear Quarter Panel
Rear-end
None of These

I was a pedestrian
Other (On bike, motorcycle, etc...)

5. How long has it been since the car accident that caused this problem?

    Click Here Less than 3 months 3 months to 1 year 1-2 years 2-3 years 3-5 years 5-10 years 10-20 years 20+ years

6 How much money did it cost to fix your car or vehicle?

    Click Here Under $500 $500-$1,500 $1,500-$2,500 $2,500-$5,000 $5,000+

7. Which one word best describes your accident related dizziness?

    Click Here Light Headed Off Balance Room Spins My Head Spins Sea sickness (nuesea)

8. Do you have problems with your vision since the accident?

    Click Here No, nothing out of the ordinary Yes, some problems, but nothing that prevents me from doing things Yes, significant problems that prevent me from doing things

9.  How severe is your dizziness, imbalance, or vertigo?

    Click Here Doesn't prevent from doing the things I want to do Sometimes keeps from doing the things I want to do Always keeps me from doing the things I want to do

10. Did you have dizziness, imbalance, or vertigo prior to this car accident?

Click Here Yes, accident didn't change my condition Yes, but accident made my condition worse No, never had a problem like this before the accident

11.  What type of things cause or worsen your dizziness, imbalance, or vertigo?

    Looking Up    Looking Down    Looking Right    Looking Left

    Traction         Chiropractic       Exercise             Looking at Window Blinds

    Watching Traffic Go By                  Reading              Stress