Vestibular Rehabilitation Intake Form
Form Preview
Vestibular Rehabilitation Intake Form
Page 1 of 3
Sign up and start customizing in minutes.
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.
How to use the Vestibular Rehabilitation Intake Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Vestibular Rehabilitation Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Vestibular Rehabilitation Intake Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 18 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Vestibular Rehabilitation Intake Form HIPAA compliant?
Yes. All Formisoft templates, including the Vestibular Rehabilitation Intake Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 18 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Vestibular Rehabilitation Intake Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Vestibular Rehabilitation Intake Form for your practice. Set up in minutes.
Related templates
Physical Therapy Intake Form
PT-specific intake with injury mechanism, pain assessment (VAS scale), functional limitations, range of motion goals, and treatment expectations. For physical therapy, sports medicine, and rehabilitation clinics.
Neurology Intake Form
Neurology-specific intake with headache assessment, seizure history, cognitive screening, neurological symptom checklist, and prior imaging review. For neurologists, headache centers, and epilepsy clinics.
Concussion SCAT Assessment Form
Sport Concussion Assessment Tool (SCAT) form for standardized sideline and clinical evaluation of suspected concussions following head injuries.