Medical Screen Form

Name *
Name
Address *
Address
Phone *
Phone
Date *
Date
Date of Birth
Enter the name of the physician if you were referred to The Dizzy Clinic. If you were not referred, how did you hear about The Dizzy Clinic?
Symptoms
Check all that apply.
ie- getting out of bed, driving.
ie- minutes, hours, days, constant, intermittent.
If Yes, please explain.
ie- Physical Therapy, Acupuncture, Medications. Please describe.
Please describe any falls in the past year.
Do you have pain? *
If yes, please describe below.
If applicable, please describe pain location.
Have any of the following occurred in the past 6 months? *
Check all that apply.
Do you have a history of any of the following. *
Please check all that apply.
Include surgeries.
Add any information that you feel may be important.