Mal de Debarquement Questionnaire

The following questionnaire is designed for people who are currently experiencing, or have experienced in the past, symptoms of "prolonged" Mal de Debarquement (more than two weeks of a persistent rocking, disequilibrium sensation).

Please do not submit a survey if you have never experienced MDD.

Please take your time, and answer all questions fully. If you have any questions, contact Evan Torrie.

Vital Statistics
Name: (First Last)
Email:
(please use your full email address so we can get in touch if necessary)
Gender: Female     Male
Age: years
Location: City: State: Country:
Note: Your name and email address will remain anonymous and will not be published with any survey results.
Onset of MDD
Current symptoms: Are you currently experiencing what might be termed MDD symptoms (e.g. rocking, disequilibrium, G-force sensations)?
Yes No
If your answer is No, please skip ahead to the question labelled "Recurrence"
Duration: How long have you been experiencing these symptoms?
years months
Recurrence: Have you experienced a serious episode of MDD in the past ( not including your current episode if you are currently experiencing symptoms ("serious" implies has lasted for longer than 2 weeks)?
Yes No
If your answer is No, please skip to the question labelled "Precipitation"
  1. How many such episodes have you had in the past?
  2. How long was the longest episode? years months
  3. Did you recover completely (i.e. elimination of all MDD symptoms) between episodes?
    Yes No
If you are not currently experiencing MDD symptoms, please use your most recent recurrence when answering the rest of this survey.
Precipitation: What activity do you believe precipitated the onset of your MDD symptoms?
Boat/Cruise Trip
Airplane Trip
Train Trip
Car/Bus Trip
Sleeping on a waterbed
Other... (Use the box below to explain...)

Was this your first ever such activity? (e.g. your first cruise, your first plane trip?)
Yes No

How long was the duration of this activity?
days hours

Did you sleep during the trip?
Yes No

Were you on any sort of motion sickness preventative such as Dramamine or the TransDerm patch?
Yes No

Please add any relevant details about the activity/events which precipitated your MDD. For example, describe the type of craft you were on, how many times you had taken such trips before, etc. If you answered Other, please explain in detail what you think precipitated your MDD.
Symptoms/Diagnosis
Symptoms: Check (click on) the boxes corresponding to the symptoms which you ascribe to MDD
Rocking G-Force inside head Dizziness
Head tremors Tilted vision Difficulty maintaining balance
Ear pain Headaches General motion sensation
Memory problems Concentration problems Anxiety
Depression Fatigue Spaced-out feeling
Other (describe below...)

Describe concisely in your own words your MDD symptoms

Pre-existing: Did you have any of the following conditions at the time of the onset of your MDD symptoms?
Ear infection Cold Sinus infection Nasal infection
Unusual stress Unusual fatigue Other...

Give any extra information about preexisting conditions at the time of your MDD onset (e.g. medications which you were on at the time)

Diagnosis: Have you been officially diagnosed by a medical professional as having Mal de Debarquement?
Yes No

If your answer is Yes

  1. How long did it take to get an official diagnosis? years months
  2. Who made your diagnosis?
    Family Doctor ENT Specialist Neurologist Psychiatrist
    Other   describe

If your answer is No

  1. Which of the following types of doctors have you seen? (check all that apply)
    Family Doctor ENT Specialist Neurologist Psychiatrist
    Other   describe

For both positive and nonpositive diagnoses, please enter any comments you may have on your diagnosis process (e.g. tests you have tried, attitudes of doctors etc)
Other Diagnoses: Many MDD patients are misdiagnosed with other ailments. Indicate which of the following diagnoses has been suggested as the reason for your symptoms by medical professionals:
Chronic ear/sinus infection Meniere's Disease Multiple Sclerosis Brain tumor
Benign Positional Vertigo Stress/Anxiety Depression Acoustic neuroma
Other...

Enter any additional comments about other diagnoses:

Treatment
  Which of the following treatments have you tried, and for each, rate its effectiveness in alleviating your MDD symptoms (check the box on the left corresponding to each treatment you have tried, and then click on the popup menu to select the effectiveness of that treatment):
Drugs:
Klonopin/Clonazepam
Tofranil/Imiprimine
Elavil
Valium
Antivert
Scopoderm patch
Prozac
Paxil/Aropax
Zoloft
Other In the box below, enter each other drug you have tried, together with its effectiveness on the MDD symptoms
Med procedures:
Surgery
Physical Therapy
Other In the box below, enter each any other conventional medical procedures you have tried, and rate their effectiveness
Alternative med:
Hypnosis
Acupuncture
Homeopathy
Herbs
Tai Chi
Meditation/Yoga
Other In the box below, enter each any other alternative medical procedures you have tried, and rate their effectiveness
General: Make any other general comments about the treatments/methods you have tried. For example, for treatments which have had some success, indicate the duration and degree (e.g. drug dosage)
Post-MDD Events
Current Level: On a scale of 1 to 10 (1 = no symptoms, 10 = the worst you've experienced), rate how you currently feel with regard to your MDD symptoms.

Scale (1-10):  

Repeating Activity: Have you undertaken the activity which originally precipitated your symptoms since the onset of MDD? (e.g. taken another boat trip, plane flight)?
Yes No

If your answer is Yes
How did you feel

  1. During the activity itself (e.g. during the cruise/flight)
  2. After the activity (e.g. back on stable land)
Alleviation: What (if any) activities/substances alleviate (reduce your awareness) of your MDD symptoms?
Walking Playing sports Travelling in vehicles Aeroplane flights
Lying motionless Sitting still Reading Drinking alcohol
Caffeine Nutrasweet Scopolamine patches
Watching movies/television Other...

Enter any additional comments or other activities which alleviate your symptoms

Aggravation: What (if any) activities/substances aggravate (increase your awareness) of your MDD symptoms?
Walking Playing sports Travelling in vehicles Aeroplane flights
Lying motionless Sitting still Reading Drinking alcohol
Caffeine Nutrasweet Scopolamine patches
Watching movies/television Other...

Enter any additional comments or other activities which aggravate your symptoms

Anaesthesia: Have you been anaesthetised for any reason since your onset of MDD (e.g. major surgery)?
Yes No

If your answer is Yes Did you feel any differently afterwards?

Lifestyle
Employment: Are you currently in paid outside employment? Yes No

If your answer is Yes

  1. What is your job description?
  2. How much time have you had to take off work because of MDD?
  3. Have you had to reduce your work hours? Yes No
  4. Have you had to change to a less demanding job? Yes No

If your answer is No

  1. Did you have to give up paid employment because of your MDD symptoms?
    Yes No

Both Yes and No continue here...

If your MDD symptoms have affected your ability to work (e.g. reduced hours, or giving up a job entirely), have you been able to obtain any disability remuneration? Yes No Haven't tried

Give any other comments related to how MDD has affected your ability to work (both paid and unpaid employment):
Daily Activities: How many hours per day do you normally spend (type in a number between 0 and 24)...?
Sleeping: Seated: On your feet: In front of a computer:
Weekly Activities: How many hours per week do you spend doing the following activities?
At work: Watching TV/movies: Reading:
Walking/running: Other physical sports:
Concentration: Has MDD affected your ability to concentrate/plan tasks?
Yes No

If your answer is Yes Give examples of the kinds of tasks that you have difficulty with and indicate to what degree you feel your concentration is affected.

Vision: Do you normally wear correcting lenses (glasses or contacts)?
Yes No

Has your vision gotten worse since the onset of MDD?
Yes No

General: Do you think that you will ever be rid of your MDD symptoms?
Yes No

Finally, give any general comments which you think would be of interest:

OK, that's all folks! Please review your answers one last time, and then press the Submit Survey button below to save your survey