Name:_________________________________________________________________________________________

Address:___________________________________________________________State:_________Zip:____________

Home#:_______________________________Work#:_____________________________ DOB:_______________

Email:___________________________________________________________________ Status: M / S / W / D

SSN:__________-________-___________Referred by:___________________________________________________

Check if applicable: Major Medical / Worker’s Compensation / Medicaid / Medicare / Auto Injury

Medical Savings Account & Flex Plans / Other:__________________________________________________

Primary Insurance:________________________________________________________________________________

Secondary Insurance:_____________________________________________________________________________

Occupation:______________________________________Employer:_______________________________________

Phone:________________________________ Status: Employed / Unemployed / Student

Case History/Patient Information

Financially Responsibility and Assignment of Benefits: I hereby sign, transfer, and set over to this office all of my rights, title, and interest to my medical reimbursement benefits under my insurance policy. I authorize payment of insurance benefits directly to the office. I authorize the release of any medical information needed to determine these benefits. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am responsible for all costs of care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.

Consent Form for Therapy

1. I, the undersigned, do hereby agree and give consent for medical care and treatment necessary in treating my physical condition.

2. I further acknowledge that the purpose of the care, risks of the recommended care and the risks of foregoing this care have been fully explained to and understood by me.

3. I recognize that the practice of therapy is as much an art as a science, and therefore acknowledge that no guaranties have been or can be made regarding the likelihood of success or outcome of any therapy.

4. I also recognize that therapy care may involve the touching of my body by members of the Clinic’s professional staff and that full or partial disrobing may be required to facilitate such care, all of which is expressly consented to by me.

5. I agree to cooperate fully and to participate in all therapy care procedures, to comply with the plan of care as it is established and to pay Clinic’s charges for such care upon my receipt of Clinic’s invoice for such care.

The patient understands and agrees to allow this office to use their Patent Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We encourage you to read the HIPAA Notice that is available to you at the front desk before signing the consent.

I have read the above and I certify that I have had an opportunity to discuss the contents thereof to my satisfaction. By signing below, I am hereby consenting to the therapy care and financially responsibility as described above.

Patient Signature: __________________________________________________________________Date:______________________

Guardian Signature Authorizing Care: _______________________________________________________________

Dizziness Questionnaire Name:_______________________________ Date:___________

Section I : Please describe your symptoms in your own words without using the word dizziness:

Section II1. Date of onset: ____________________ 2. Was it associated with a related event? Ex. Head injury □ yes □ no

a. explain:_____________________________________________________________________3. Was the onset? □ sudden □ gradual □ overnight □ other__________________________________4. Are the symptoms: □ constant □ variable (come and go)

a. If variablei. Spells occur ________ times in □ one day □ one week □ one month

ii. Do you have warning signs for the spells? □ yes _______________ □ noiii. Are you completely free of symptoms between spells? □ yes □ noiv. How long do the spells last? □ sec □ min □ hours □ days □ constant

5. Do your symptoms occur when changing positions? □ yes □ no Check below all that apply

Rolling your body to the left Rolling your body to the right Moving from a lying to a sitting position Looking up with your head back Turning head to side while sitting/standing Bending over with your head down

Section IIIPlease check the symptoms associated with your spells and rate the severity from 1-10, 10 being the most severe

1-10 1-10 1-10Spinning sensation Black out Difficulty SwallowingTilting Loss of consciousness Difficultly speakingFeel being pushed to side Memory loss Double visionlightheadedness Seizures Weakness on one side of the bodyclumsiness Abnormal Gait Localized headache

Section IV1. Do you have hearing loss? □ yes □ no Which side? □ right □ left □ both2. Do you have ringing in the ear or other similar noises? □ yes □ no Which side? □ right □ left □ both3. Do you have fullness in the ears? Yes No Which side? □ right □ left □ both4. Did your ear symptoms occur at the same time as your dizziness/imbalance symptoms? □ yes □ no

Section V1. Do you have history of falls?

a. Number of falls :___________ in □ week □ month □ year 2. Do you have fear of falling? □ yes □ no3. Most recent date of fall: ____________________________

a. Describe: _______________________________________________________________Additional Comments:______________________________________________________________________________

_________________________________________________________________________________________________

Review of SystemsCheck below if you have now or have had previously- mark with N for Now and P for previous condition

Musculoskeletal P/N Psych/Neuro P/N Eye/ENT P/NOsteoporosis Anxiety Dimension ChangesArthritis Depression Blurred VisionScoliosis Memory Loss Double VisionNeck Pain Loss of sleep EaracheHip Disorder Headache Hearing LossKnee Injury Dizziness Ringing in earsFoot/ankle Pain Pins/needles Ear infectionsShoulder Pain Numbness HoarsenessElbow/wrist Pain Loss of smell Sore ThroatTMJ issues Loss of taste Difficulty SwallowingPoor Posture

Cardiovascular P/N Respiratory P/N Gastrointestinal P/NChest pain Cough NauseaPalpitations Short breath VomitingShortness of breath Asthma Abdominal PainLightheadedness Emphysema HeartburnHypertension Hay Fever Ulcer hypotension Pneumonia Food SensitivityHigh Cholesterol Wheezing Changes in bowelAnkle Swelling Constipation

DiarrheaBlood in stool

Geniturinary P/N Endocrine P/N Derm/ Hemo P/NPainful urination Diabetes RashesFrequent urination Hot Intolerance Hyper pigmentationUrgency Cold intolerance Hypo pigmentationIncontinence Hyperthyroid Excessive acne

Hypothyroid EczemaImmunology Pancreatic condition PsoriasisAutoimmune Excessive urine Skin CancerImmune deficiency Increased thirst Excessive hair loss

Easy BruisingBleeding gums

Diagnosis P/N Diagnosis P/N Diagnosis P/N Diagnosis P/NMigraines Seizures Tumor StrokeMultiple Sclerosis Neuropathy Panic Attacks/Anxiety Congestive heart

failureConcussion Depression Cervical Spine Arthritis Diabetes MellitusGlaucoma Macular Degeneration Parkinson’s Disease Ataxia

Contraindications: Check yes or noRelative Y N Absolute Y N Y NArticular Hypermobility Disease Rheumatoid Arthritis FractureSevere Demineralization of Bone Ankylosing Spondylitis Myelopathy

Benign Bone Tumor (spine) Dislocation: Cuada EquinaBleeding disorder Unstable Os Odontoedeum Vertebrobasilar Are you on an anti-coagulant? Malignancies in spine Aneurysm

Past History/Family/Social Surgeries: __________________________________________________________________________________________

__________________________________________________________________________________________________

Illnesses: __________________________________________________________________________________________

________________________________________________________________________________________________

Accidents/Fractures: _________________________________________________________________________________

__________________________________________________________________________________________________

Are you currently taking any medications? □ No □ Yes (Please include regularly used over the counter medications)

Medication Name For what use Dosage and Frequency

Do you have any drug allergies? □ No □ Yes, If so list: _______________________________________________________

Family History of: □ Diabetes □ Cancer □ Hypertension □ Neurological □ Stroke □ Other: _____________________

Work: □ Full time □ Part-time □ Unemployed □ Retired □ Student □ Disabled Describe work: ____________________

Social: □ Alcohol amount: ______ □ Smoke # per day: _________ □ Caffeine # per day: _____ □ Recreational Drugs

Exercise: Daily / Few times a week / none Type of Exercise: ____________________________________________

Diet: __________________________________________________ Cups of water per day:_______________________

Supplements: ______________________________________________________________________________________

I certify the information provided is accurate to the best of my knowledge:

Patient Name – Print_________________________________________________________________________________

Signature__________________________________________________________________________________________

Date__________________________________