Prepare for Your Visit with Easy Access to Forms

Please complete the first questionnaire if you are coming to our office for vertigo, dizziness or balance issues. Complete the second questionnaire if coming to us for an orthopedic condition. Type directly into the form and SUBMIT when completed. Any additional information you have (ie. Physician prescription, Test results etc), please bring them with you at the time of your scheduled appointment.

Health Questionnaire – Vestibular/Balance

"*" indicates required fields

This field is for validation purposes and should be left unchanged.
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Medical History: (“X” all that apply)– Have you had a history of, or are presently experiencing, any of the following:
Diabetes
Do you smoke?
Do you have any pain?
IF YOU HAVE A LIST OF MEDICATIONS, PLEASE PROVIDE. Otherwise, complete below…. Please list any prescription or non-prescription medication or are taking? (Include vitamins and herbal supplements):
List
Medication
Dosage
Frequency
Route (i.e., oral, injection)
 
Are you taking, or have you taken, any medications for the condition for which you are seeing the Physical Therapist?
Have you seen a Physical Therapist for this condition in the past?
FALLS:
Have you had a fall in the past year?
Have you had 2 or more falls in the past year?
Has any fall resulted in an injury?
Do you have a fear of falling?
Living Situation:
Stairs in home?
Railing?
Please describe the symptoms you have been feeling: (“X” all that apply)
What makes your vertigo, dizziness or balance worse? (“X” all that apply):
Have you ever been involved in a car accident or ever had a blow to the head (with or without loss of consciousness)?
Retired?
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Health Questionnaire-Orthopedic

"*" indicates required fields

This field is for validation purposes and should be left unchanged.
MM slash DD slash YYYY
MM slash DD slash YYYY
Medical History: (“X” all that apply)– Have you had a history of, or are presently experiencing, any of the following:
Diabetes
Do you smoke?
IF YOU HAVE A LIST OF MEDICATIONS, PLEASE PROVIDE. Otherwise, complete below…. Please list any prescription or non-prescription medication or are taking? (Include vitamins and herbal supplements):
List
Medication
Dosage
Frequency
Route (i.e., oral, injection)
 
Have you seen a Physical Therapist for this condition in the past?
Do you have any pain?
Level Of Pain 0= None 5= Moderate 10= Extreme
At Worst
Current:
At Best:
Describe your pain: (X all that apply) Other
What relieves your pain/symptoms? (“X” all that apply):
Retired?
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