Vestibular Rehabilitation Therapy Intake

Vestibular Rehabilitation Therapy Intake — Form Fields

This healthcare template includes 14 fields. Intake form for patients beginning vestibular rehabilitation for dizziness and balance disorders. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Birth (text, required)
• Email (email, required)
• Phone Number (text, required)
• Referring Physician (text, required)
• Primary Symptom (dropdown selection, required) — options: Vertigo (spinning), Dizziness (lightheaded), Imbalance, Motion Sensitivity, Visual Disturbance, Oscillopsia
• Diagnosis (if known) (dropdown selection, optional) — options: BPPV, Vestibular Neuritis, Meniere's Disease, Labyrinthitis, Concussion-Related, Acoustic Neuroma, Bilateral Vestibular Loss, Unknown
• Symptom Duration (dropdown selection, required) — options: Days, Weeks, 1-3 Months, 3-6 Months, 6-12 Months, Over 1 Year
• Triggers (checkboxes, optional) — options: Head Movement, Position Changes, Visual Stimulation, Walking, Standing, Stress, Weather Changes, None Identified
• Number of Falls in Past 6 Months (number, optional)
• Currently Using Assistive Device (multiple choice, required) — options: Yes - Cane, Yes - Walker, Yes - Wheelchair, No
• Impact on Daily Activities (dropdown selection, required) — options: Minimal, Moderate, Significant, Severe - Housebound
• Medication List (long text, optional)
• Goals for Rehabilitation (long text, required)