Vestibular Rehab Physical Therapy Intake Form
Personal Information
First Name
Last Name
Date of Birth
Phone Number
Email
Address
Referral / Physician
Referring Physician Name
Physician Phone Number
Medical History
Current Diagnosis / Reason for Visit
When did your symptoms begin?
Check any symptoms you experience:
Dizziness
Vertigo
Imbalance
Falling
Nausea
Hearing Loss
Ringing in Ears
Vision Problems
List any other medical conditions
List current medications
Recent Falls (number, details)
Symptoms Details
How often do you experience your symptoms?
What triggers or worsens your symptoms?
What relieves your symptoms?
Have you had any previous treatment or therapies for this problem?
Functional Impact
How do these problems affect your daily activities?
Any activities you avoid?
Goals
What are your goals for physical therapy?