Vestibular Rehabilitation Intake Form
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Vestibular Rehabilitation Intake Form
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This comprehensive vestibular rehabilitation intake form is designed for physical therapists and occupational therapists specializing in balance and dizziness disorders. It systematically captures the patient's experience with vertigo, lightheadedness, spatial disorientation, and related symptoms, including triggers, duration, and impact on daily activities. The form includes standardized questions about fall history, motion sensitivity, and visual disturbances that are critical for diagnosing vestibular conditions.
The template guides clinicians through essential information collection including medication review (particularly vestibular suppressants), prior diagnostic testing such as VNG or ENG results, and functional limitations in activities like driving, reading, or walking in crowded spaces. It also screens for red flag symptoms requiring immediate medical attention, documents previous treatment attempts, and establishes baseline activity tolerance. This structured approach ensures thorough evaluation while helping therapists develop individualized treatment plans for conditions like BPPV, vestibular neuritis, labyrinthitis, and persistent postural-perceptual dizziness.
What's included
- Detailed dizziness and vertigo symptom assessment
- Fall risk history and frequency
- Motion sensitivity and visual triggers
- Functional limitation inventory
- Medication and supplement list
- Prior diagnostic test results
- Balance confidence scale questions
- Driving and work impact assessment
- Emergency contact information
- Insurance verification details
Who uses this template
- Vestibular Rehabilitation Clinics
- Balance Disorder Centers
- Neurological Physical Therapy Practices
- ENT Specialty Clinics
- Concussion Recovery Programs
All form fields
9 fields across 3 pages. Customize any field after signing up.
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