This BPPV Screening and Assessment Form is a specialized client intake form for healthcare providers evaluating patients with vertigo or dizziness. It gives clinicians a clear way to collect patient identifiers, symptom onset, episode frequency, episode duration, and other details that help distinguish positional vertigo from broader dizziness complaints.
The template is structured for practical clinical use. In addition to basic intake fields such as name, date of birth, age, contact information, assessment date, and referring provider, it supports documentation of vertigo triggers, positional testing such as the Dix-Hallpike maneuver, fall risk concerns, and whether vestibular rehabilitation referral should be considered.
Because the questions are organized in a logical clinical flow, this patient intake form can help reduce missing information during evaluation and make assessments easier to review later. It is a strong fit for physical therapy clinics, rehabilitation settings, primary care practices, and other healthcare teams that need consistent BPPV screening documentation.
