Transcription of PT/OT INITIAL EVALUATION REPORT FOR …
1 Today s Date: PT/OT INITIA L EVALUATION REPORT FOR VES TIBULAR DYSFUNCTION Insurance Company: Pat ient Name: Pat ient ID #: Date of Bi rth / Age: Date of Onset of Symptoms: / / ICD-10 Code(s): Diagnosis: Referring Physician Name (Specialty): Referring Physician ID #: Therapy Offi ce: Discipline: PT / OT History of present illness: Prior Level of function: PMH: Medications: Please provide information on the following tests (if done): Hallp ike - Dix: Static balance testing: Gaze Stabilization (VOR): Dynamic balance testing: Dizziness Handicap Inventory Score: Berg Balance Scale Score: Neurological/functional defici ts: Treatment Plan: Frequency of treatment: Therapist Signature: Printed Name and License #: Copyright 2015 OrthoNet, LLC Created: 1/06 / Revised: 1/12, 10/15
