Chronic Vestibular Migraine Assessment & Dizziness Diary

Comprehensive Vestibular Migraine Assessment Template

Chronic vestibular migraine is a complex neurological condition that affects millions of people, causing debilitating dizziness, vertigo, and migraine symptoms that can significantly impact daily life. Our Chronic Vestibular Migraine Assessment & Dizziness Diary template is designed specifically for healthcare providers, neurologists, neuro-otologists, and headache specialists who need a systematic approach to evaluating and tracking vestibular migraine symptoms.

Why this form is essential for healthcare practices

Accurate diagnosis of vestibular migraine requires careful documentation of symptoms, triggers, and patterns over time. This comprehensive assessment form combines initial patient intake, detailed symptom tracking, and clinical evaluation criteria into one streamlined workflow. Whether you're a neurology practice, ENT specialist, or headache clinic, this template helps you:

• Gather comprehensive patient history including migraine patterns, vestibular symptoms, and previous treatments
• Track dizziness episodes systematically with a built-in diary component for ongoing symptom monitoring
• Apply diagnostic criteria from the International Classification of Headache Disorders (ICHD-3)
• Streamline referrals to neurology or neuro-otology specialists when needed
• Document functional impact on daily activities and quality of life

Built for modern healthcare workflows

This Paperform template replaces messy paper forms and fragmented intake processes with a clean, professional digital experience. Patients can complete the assessment remotely before their appointment, saving valuable clinic time and ensuring you have all the information you need for accurate diagnosis. The conditional logic guides patients through relevant sections based on their symptoms, while required fields ensure no critical information is missed.

Automatic workflow triggers with Stepper: Connect this form to Stepper to automatically route completed assessments to the appropriate specialist, trigger follow-up appointment scheduling, send patient education materials, or update your EMR system. You can build sophisticated clinical pathways that respond to specific symptom combinations or severity scores without writing a single line of code.

Secure eSignatures with Papersign: Need patient consent for referrals or treatment plans? Use Papersign to automatically generate consent forms based on assessment results and collect legally binding eSignatures, keeping everything connected to the original patient data.

Ideal for neurologists, ENT specialists, and headache clinics

This template is trusted by healthcare providers who specialize in:

• Neurology practices evaluating chronic headache and migraine patients
• Neuro-otology clinics assessing vestibular disorders
• ENT specialists differentiating vestibular migraine from other balance disorders
• Headache centers providing comprehensive migraine care
• Primary care providers screening patients before specialist referral
• Physical therapy practices treating vestibular rehabilitation patients

The form uses clinical terminology and assessment criteria familiar to healthcare professionals while remaining patient-friendly and easy to complete. Questions are structured to align with ICHD-3 diagnostic criteria for vestibular migraine, making it easier to identify patients who meet clinical thresholds for diagnosis.

Features that improve clinical outcomes

Unlike generic health forms, this template includes specialized components for vestibular migraine assessment:

• Detailed dizziness characterization distinguishing vertigo, lightheadedness, imbalance, and other vestibular symptoms
• Migraine-specific history capturing aura symptoms, photophobia, phonophobia, and other diagnostic features
• Trigger identification for both vestibular symptoms and headaches
• Medication history including preventive and acute treatments
• Functional impact assessment using standardized disability scales
• Comorbidity screening for anxiety, depression, and other conditions that affect treatment

The multi-page layout organizes information logically, preventing patient overwhelm while ensuring comprehensive data collection. Conditional questions appear only when relevant, creating a personalized assessment experience that adapts to each patient's unique symptom profile.

HIPAA considerations and data security

While Paperform is not HIPAA compliant, this template is designed with privacy best practices in mind. For healthcare providers requiring HIPAA compliance, we recommend using this template in combination with HIPAA-compliant systems through secure integrations, or using it for pre-screening and intake coordination rather than storing protected health information. Always consult with your compliance team to ensure your implementation meets regulatory requirements.

Seamless integration with your existing tools

This assessment form connects easily with the healthcare technology stack you already use. Send completed assessments to your EMR via Stepper or webhooks, log referrals in your practice management system, notify staff via Slack when urgent cases require immediate attention, or compile results in Google Sheets or Airtable for research and outcomes tracking.

The form is fully customizable to match your practice branding, clinical protocols, and specific assessment needs. Add your logo, adjust questions to reflect your patient population, incorporate your clinic's rating scales, or modify referral pathways to align with your specialist network.

Get started in minutes, not hours

With over 30,000 designer templates and AI-assisted form building, Paperform makes it easy to deploy professional healthcare assessments quickly. This vestibular migraine template is ready to use immediately or can be customized to your exact specifications. No coding required, no IT department needed—just a powerful, flexible form platform built for healthcare providers who want better patient experiences and more efficient workflows.

Whether you're evaluating a new patient with chronic dizziness or tracking treatment response over time, this comprehensive assessment template gives you the structured data you need for accurate diagnosis, effective treatment planning, and improved patient outcomes.