Vestibular Rehabilitation Pre-Screening & Appointment Booking

Book Your Vestibular Rehabilitation Assessment with Confidence

If you're experiencing dizziness, vertigo, or balance issues, vestibular rehabilitation therapy can help you regain stability and confidence in your daily movements. This comprehensive pre-screening form helps your healthcare provider understand your symptoms, fall history, and overall health before your first appointment.

Why Vestibular Rehabilitation?

Vestibular rehabilitation is a specialized form of physical therapy designed to alleviate problems caused by vestibular disorders. Whether you're dealing with BPPV (benign paroxysmal positional vertigo), vestibular neuritis, or age-related balance decline, a thorough initial assessment is crucial for developing an effective, personalized treatment plan.

How This Form Helps Your Care

By completing this detailed intake form before your appointment, you enable your therapist to:

• Review your medical history and understand the full scope of your symptoms
• Assess fall risk factors to ensure safety during your evaluation and treatment
• Identify medication interactions that may affect your balance or dizziness
• Prepare appropriate assessment tools tailored to your specific condition
• Plan a home exercise program you're committed to following between sessions

This pre-screening approach means your first appointment can focus on hands-on assessment and treatment rather than paperwork, maximizing the value of your time with your healthcare provider.

Perfect for Healthcare Practices and Rehabilitation Centers

This template is ideal for physical therapy clinics, balance and vestibular centers, neurology practices, and audiology clinics offering vestibular rehabilitation services. It meets the needs of practices serving older adults, post-concussion patients, and anyone dealing with dizziness or balance disorders.

Streamline Your Intake with Paperform

Built on Paperform's flexible platform, this vestibular rehabilitation form can be customized to match your clinic's branding and workflows. The integrated appointment booking feature connects directly to your calendar, eliminating double-booking and back-and-forth emails. Conditional logic ensures you only ask relevant follow-up questions based on patient responses, creating a smooth, personalized experience.

Need to route urgent cases differently? Use Stepper (stepper.io) to automatically trigger different workflows based on fall frequency or symptom severity—flagging high-risk patients for priority review, sending confirmation emails with pre-appointment instructions, and updating your practice management system without manual data entry.

For practices requiring signed consent forms before treatment begins, integrate Papersign (papersign.com) to automatically send treatment agreements and liability waivers for eSignature once the intake form is submitted, keeping everything connected and compliant.

With SOC 2 Type II compliance and robust security features, Paperform ensures your patient data stays protected while giving your administrative team the autonomy to manage forms, bookings, and workflows without IT support.