Vestibular Physical Therapy Assessment
Patient Information
Name
Date
Age
Sex
Male
Female
Other
Chief Complaint
History of Present Illness
Medical History
Symptoms
Dizziness
Yes
No
Vertigo
Yes
No
Imbalance
Yes
No
Other Symptoms
Medication
Objective Exam
Oculomotor Tests
Positional Testing
Balance / Gait Assessment
Assessment / Impression
Treatment Plan