Vestibular and Dizziness Physiotherapy Assessment Form — Interactive

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Vestibular / Dizziness Assessment Form

Full vestibular physiotherapy assessment — history, otology screen, oculomotor/VOR/positional testing, functional outcome measures, diagnosis and treatment plan. Fill it in, it saves as you go, then generate a clean report to print, copy or share.

🇦🇺 Australia
⚠️ For physiotherapists and other clinicians assessing dizziness/vertigo. This is a structured documentation tool — it does not interpret findings or suggest a diagnosis. Clinical judgement and appropriate training (e.g. in oculomotor/positional testing) remain entirely yours. Not medical advice.
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100% private. Everything you type is stored only in this browser on this device — no accounts, no uploads. Clearing browser data deletes it. Use Print/Copy/Share to hand the report to your record system.
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🙋 Patient & referrer
📋 History of presenting condition
Date of onset · gradual vs sudden · description & duration · constant/intermittent · aggravating/alleviating symptoms · associated symptoms · precipitating illness · current main problem
One, few or many · secs, mins, hours, days
Current provoking factors
Tap any that apply. Where marked, tap L and/or R.
Medication, lying down, keeping still, avoidance
🗂️ Social, falls & medical history
Function previous/current · alcohol · cigarettes · caffeine
Living situation
Vestibular suppressants & ototoxic medications — tap to add, or type freely
👂 Otology history
* = audiological assessment indicated  ·  ** = audiological-vestibular assessment indicated
e.g. noise exposure, hearing aids
🩺 Associated symptoms
🧠 Migraine questionnaire
🦴 Cervical spine screen
👁️ Oculomotor assessment
Tap a chip to fill the last cell you tapped in the table below — still fully editable.
🎯 VOR testing
🔄 Positional testing
Tap a chip to fill the last cell you tapped in the table below — still fully editable.
👓 Dynamic visual acuity (DVA)
DVA difference: — enter both values
Drop of 1–2 lines = normal · drop of 3 or more lines = abnormal
🚶 Functional outcome measures
Three timepoints, side by side — fill in whichever apply.
Functional Gait Assessment (10 items, /30 total)
🔊 Fistula testing
Tragal pressure / valsalva against pinched nostrils and closed glottis >10 secs
Own sustained singing of "E" >10 secs
📝 Subjective outcome measures
🔍 Impression / diagnosis
💡 Treatment plan

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📋 Source: Digitised from a standard vestibular physiotherapy assessment proforma (history, otology screen, oculomotor/VOR/positional exam battery, functional outcome measures including Functional Gait Assessment, fistula testing). Structure and content reproduced as a fillable form only — this tool does not interpret results, score risk, or suggest a diagnosis. Not medical advice. Last verified: July 2026.