Welcome to the Comprehensive Sensory & Vestibular Health Assessment. This form evaluates the health of your eyes, ears, and inner-ear balance system. Accurate answers help identify early signs of sensory decline and guide personalized recommendations.
Full name
Date of birth
Preferred contact email
Primary language for communication
I consent to the use of my anonymized data for research to improve sensory health assessments.
Do you currently wear corrective lenses (glasses or contact lenses)?
Have you ever been diagnosed with an eye condition?
Do you experience digital eye strain (computer vision syndrome)?
Have you had any eye surgeries or procedures?
Over the past month, how often have you experienced the following?
Never | Rarely | Sometimes | Often | Always | |
|---|---|---|---|---|---|
Blurred distance vision | |||||
Blurred near vision | |||||
Double vision | |||||
Halos around lights | |||||
Difficulty with night driving due to glare | |||||
Frequent changes in prescription | |||||
Eye pain or discomfort | |||||
Sudden appearance of floaters or flashes |
How would you rate your overall vision satisfaction?
Very dissatisfied
Dissatisfied
Neutral
Satisfied
Very satisfied
Do you use screen-darkening features (dark mode) to reduce discomfort?
On average, how many hours per day do you spend on screens (phones, tablets, computers, TVs)?
Have you ever had a hearing test (audiogram)?
Do you currently use hearing aids or amplifiers?
Have you been exposed to loud noise at work or during leisure?
Do you experience tinnitus (ringing or buzzing in the ears)?
Indicate the level of difficulty you have in the following situations
No difficulty | Mild difficulty | Moderate difficulty | Severe difficulty | Cannot do | |
|---|---|---|---|---|---|
Understanding speech in quiet | |||||
Understanding speech in background noise | |||||
Haring high-pitched sounds (e.g., birds) | |||||
Localizing where sounds come from | |||||
Using phones without amplification | |||||
Following rapid conversation |
Do you often ask people to repeat themselves?
Describe any ear-related surgeries, infections, or injuries
How would you rate your overall hearing satisfaction?
Very dissatisfied
Dissatisfied
Neutral
Satisfied
Very satisfied
Have you ever experienced vertigo (a spinning sensation)?
Have you ever been diagnosed with a vestibular disorder?
Have you had a vestibular (balance) test such as VNG or rotatory chair?
Do you feel unsteady when walking in the dark or on uneven surfaces?
Over the past 3 months, rate the frequency of the following
Never | Rarely | Sometimes | Often | Always | |
|---|---|---|---|---|---|
Light-headedness on standing | |||||
Feeling of floating | |||||
Drifting to one side while walking | |||||
Need to hold walls or furniture | |||||
Difficulty walking heel-to-toe | |||||
Motion sickness (car, boat, VR) |
Have you fallen in the past 12 months?
Rate your confidence in balance on a scale of 1 (very low) to 10 (very high)
Which best describes your current activity level?
Sedentary (mostly sitting)
Light activity (walk daily)
Moderate (exercise 2-3×/week)
Active (exercise 4-5×/week)
Athletic (intense training)
Our brain combines vision, hearing, and vestibular inputs to orient us in space. Difficulties can manifest as clumsiness, disorientation, or anxiety in busy environments.
Do you feel overwhelmed in supermarkets, malls, or crowded streets?
Do you avoid driving at night or in heavy traffic?
Rate the challenge level of the following tasks
No challenge | Mild | Moderate | Severe | Avoid completely | |
|---|---|---|---|---|---|
Walking while looking at your phone | |||||
Navigating escalators | |||||
Riding elevators | |||||
Walking across patterned carpets | |||||
Turning your head quickly to respond to someone |
Do you experience 'sensory overload' in noisy or visually busy environments?
Which protective measures do you regularly use?
UV-blocking sunglasses
Blue-light filtering glasses
Earplugs at concerts
Noise-canceling headphones
Safety goggles
Hearing protection at work
None of the above
How often do you have eye exams?
Never
Only when problems arise
Every 2–3 years
Annually
More than once a year
How often do you have hearing checks?
Never
Only when problems arise
Every 3–5 years
Every 1–2 years
Annually
Do you smoke or vape nicotine products?
List any vitamins or supplements you take for eye, ear, or brain health (e.g., lutein, omega-3, magnesium)
Do you have diabetes?
Have you ever had a head injury or concussion?
Are you taking any medications that may affect balance (e.g., sedatives, blood-pressure drugs)?
List any other chronic conditions (e.g., migraine, hypertension, anxiety)
Please upload a recent photo of your face looking straight ahead. This helps clinicians observe eye alignment and facial symmetry but is optional.
Optional facial photo
Signature confirming information accuracy
Analysis for Sensory & Vestibular Health Assessment
Important Note: This analysis provides strategic insights to help you get the most from your form's submission data for powerful follow-up actions and better outcomes. Please remove this content before publishing the form to the public.
The Comprehensive Sensory & Vestibular Health Assessment is a meticulously engineered instrument that triangulates data across vision, hearing, and balance domains. Its modular architecture—split into nine logically sequenced sections—reduces cognitive load and allows respondents to focus on one sensory system at a time. Conditional logic (yes/no gateways, option-driven follow-ups, and dynamic tables) keeps the form concise for low-risk users while capturing granular detail for high-risk ones, a design choice that directly supports early-detection workflows in audiology and neuro-otology clinics.
From a data-quality perspective, the form enforces format validation on emails, dates, and numeric fields, and employs matrix ratings with identical Likert anchors across sections, ensuring longitudinal comparability for population-health analytics. The optional facial photograph and anonymized-research-consent checkbox demonstrate GDPR-aligned privacy thinking, while the signature field satisfies medico-legal requirements for documentation integrity.
These mandatory identifiers are foundational for patient safety: they link the questionnaire to the correct EHR record, prevent duplicate entries, and enable age-specific normative scoring for vestibular risk algorithms. The single-line text limits free-text variability, but the absence of regex validation for alphabetic characters could still allow numeric typos; adding a client-side pattern would further increase data fidelity.
Collecting DOB also unlocks age-stratified insights such as presbycusis prevalence or BPPV incidence spikes in 5th–7th decades. Making this field mandatory is therefore not just administrative—it is central to the clinical interpretability of every downstream metric.
Kept optional, this field respects privacy-minimisation principles for users who may only want in-person feedback. However, its optional status could reduce uptake of tele-audiology follow-ups or e-newsletters with tailored vestibular exercises. A midpoint strategy—auto-inviting but skippable—balances engagement with privacy.
Inclusion of this question future-proofs the service for multilingual push notifications and ensures that educational material about vestibular rehabilitation is delivered in the respondent’s dominant language, reducing health-literacy barriers. The "Other" gateway with free-text avoids forcing users into ill-fitting categories, an inclusive design win.
Mandatory consent here is ethically sound: it provides a lawful basis under GDPR Article 6(1)(a) for secondary research without which the form’s promised contribution to "improving assessments" would be hollow. The plain-language sentence avoids legal jargon, supporting e-consent validity.
These yes/no gating questions efficiently channel users: low-risk respondents skip detail tables, whereas high-risk users expand into a taxonomy of refractive-error subtypes. The multiple-choice checkboxes allow comorbid conditions to be captured, essential for poly-pathology modelling in ophthalmology clinics.
Pairing a subjective frequency matrix with an objective numeric field (hours/day) creates a blended dataset suitable for correlating CVS symptom severity with actual exposure—a design that mirrors evidence-based ergonomics research instruments.
The form’s hearing section mirrors OSHA exposure documentation, capturing both occupational and leisure sources. The table structure for duration and protection use enables dose–response modelling for future NIHL risk calculators.
Four sub-dimensions (loudness, annoyance, sleep, concentration) align with Tinnitus Functional Index sub-scores, allowing direct comparison with validated clinical endpoints without requiring a separate questionnaire.
By capturing trigger, duration, and nausea, the table format supplies the core variables needed for differential diagnosis between BPPV, vestibular migraine, and Ménière’s—three conditions with overlapping vertigo but distinct time courses.
A 0–10 Likert instead of the traditional ABC-16 scale shortens the form while preserving sensitivity to change; studies show single-item balance-confidence ratings correlate strongly (r≈0.8) with the full ABC in community-dwelling adults.
These items probe the little-studied but clinically salient area of sensory integration. Capturing avoidance behaviours (supermarkets, night driving) quantifies functional impairment beyond pure vestibular failure, supporting a more holistic view of navigation disability.
Although optional, the photo field leverages computer-vision algorithms for strabismus screening and facial asymmetry post-Bell’s palsy, adding objective data without extra respondent burden. Clear justification text mitigates privacy concerns, aligning with HIPAA minimum-necessary principles.
The form’s breadth yields a high-dimensional dataset suitable for machine-learning phenotyping of sensory aging. However, the optional status of many fields may produce missing-not-at-random patterns; clinics should plan imputation strategies or incentivize completion (e.g., personalised reports) to preserve statistical power.
Progressive disclosure keeps the initial cognitive load low, but the total number of potential questions exceeds 120 for a user with full sequelae. A progress bar or section-wise save functionality would reduce abandonment among older adults who may need multiple sittings. Colour-contrast compliance and large target zones for checkboxes would further enhance accessibility for users with presbyopia or tremor.
Mandatory Question Analysis for Sensory & Vestibular Health Assessment
Important Note: This analysis provides strategic insights to help you get the most from your form's submission data for powerful follow-up actions and better outcomes. Please remove this content before publishing the form to the public.
Full Name
Accurate linkage between questionnaire responses and the patient’s medical record is non-negotiable for patient-safety and continuity of care. A mandatory legal name prevents duplicate files and ensures that any red-flag responses (e.g., sudden-onset floaters suggesting retinal detachment) can be escalated to the correct individual without delay.
Date of Birth
Age is a primary covariate in every sensory epidemiology model—from presbyopia prevalence curves to vestibular decline trajectories. Without DOB, risk stratification becomes impossible, undermining the form’s core purpose of early detection and age-appropriate counselling.
Consent to Anonymized Research Use
Making this consent mandatory creates a uniform dataset that can be pooled for IRB-approved research aimed at refining normative thresholds and predictive algorithms. Because the form promises users that their anonymized data will "improve assessments," failing to secure consent would breach the stated value proposition and limit service-wide learning.
Signature Confirming Information Accuracy
A digital signature provides a medico-legal attestation that the respondent has reviewed the answers, reducing the likelihood of insurance fraud and ensuring that clinicians can rely on the data for diagnostic decisions. Mandatory status aligns with professional standards for electronic health records.
The current mandatory set is appropriately minimal—only 4 of ~60 fields—striking a pragmatic balance between data integrity and user burden. To optimise completion rates while preserving clinical utility, consider softening the consent and signature steps for users who explicitly opt out of research and in-person follow-up; implement a two-tier consent (clinical care vs. research) so that users uncomfortable with data sharing can still receive personalised recommendations.
For high-value optional fields (e.g., email, screen hours, fall history), introduce conditional mandation: if a respondent reports frequent vertigo or dissatisfaction with balance, dynamically require the fall-history table before submission. This risk-based approach maximises safety-critical data capture without imposing friction on low-risk users, a proven tactic to boost both data richness and form completion in geriatric e-health tools.