Please provide us with your full name and email address.

Have you fallen multiple times in the past year?

Do you experience dizziness when getting up from lying down?

Do you experience dizziness when first lying down or when washing your hair in the shower?

Do you have difficulty walking in dark environments?

Do you experience dizziness or feeling of being unstable with walking in busy environments (i.e. grocery shopping)?

Have you been limited in performance of exercise activities due to dizziness or feelings of loss of balance?

Have you restricted your driving at night or in busy environments due to feeling of dizziness?

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