Vestibular Rehabilitation Assessment Sheet
Patient Information
Name
Date of Birth
Date
History
Presenting Complaint
Duration of Symptoms
Relevant Medical History
Medications
Subjective Symptoms
Dizziness/Vertigo
Falls/Imbalance
Other Symptoms
Objective Assessment
Oculomotor Examination
Head Thrust Test
Dynamic Visual Acuity
Romberg/Tandem Stance
Gait Assessment
Other Findings
Outcome Measures
DHI Score
ABC Scale
Other
Treatment Plan
Short-term Goals
Long-term Goals
Vestibular Exercises Prescribed
Additional Notes