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I can stand at church without holding on to the pew.
– 81-year-old Betty Gross , Vancouver, WA

Downloads

It is important to determine how a patient’s dizziness or imbalance is affecting their daily life. The forms provided below will assist our clinicians in the evaluation process.

After you have downloaded and printed your form fill it out and bring the completed form with you to your appointment. 		Downloads
Vestibular/Balance Rehabilitation Forms

Vestibular/Balance Rehabilitation Forms

 
  New Patient Form
New patient form must be filled out if you are new to our clinic.

Download New Patient Form (23K PDF) 		New Patient Form
New Patient Form
(23K PDF)
  Patients experiencing dizziness and balance problems please fill out both the Dizziness Handicap Index (DHI) and the Activity Specific Balance Confidence Scale.  
Dizziness Handicap Index
If you have dizziness and are not experiencing loss of balance or falls please fill out the Dizziness Handicap Index only.

Download Dizziness Handicap Index Form (860K PDF) 		Dizziness Handicap Index
Dizziness Handicap Index
(860K PDF)
Activity Specific Balance Confidence Scale
If you have BALANCE problems and are not experiencing vertigo or dizziness symptoms please fill out the Activity Specific Balance Confidence Scale.

Download Activity Specific Balance Confidence Scale Form (88K PDF) 		Activity Specific Balance Confidence Scale
Activity Specific Balance Confidence Scale
(88K PDF)

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14411 NE 20th Avenue, Vancouver, WA 98686 | Phone: 360-256-4425 | Fax: 360-260-7249
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