Vestibular Evaluation & Treatment Note (BPPV/Dizziness)

Date/Time: [Date and time of encounter]

Patient: [Full name, DOB, MRN]

Clinician: [Name, credentials]

Visit Type: [initial evaluation / follow-up / reassessment]; Treatment performed today: [yes / no]

Precautions: [Relevant safety considerations such as fall risk, cervical limitations, vertebrobasilar concerns, nausea/emesis risk, or "none"]

(Omit sections that do not apply rather than leaving them empty. For missing clinically important information, state "unknown" or "not obtained." Do not infer absence of symptoms unless explicitly denied.)

Chief Complaint

[Primary dizziness complaint in patient's own words]

Subjective

[Dizziness characterization: onset and course; episode duration and frequency; triggers including positional changes (rolling in bed, looking up, bending, lying down); symptom quality (spinning vertigo vs lightheadedness vs imbalance); severity; functional impact on ADLs/participation; prior BPPV episodes or treatments if relevant] (State "unknown" or "not assessed" for critical items not obtained.)

[Falls or near-falls with circumstances; associated symptoms and red flag screen: new neurologic symptoms, severe/new headache, syncope, hearing changes, tinnitus, recent head trauma; patient goals in rehab context] (Document explicit denials when stated.)

Objective

Vitals/Mobility: [Relevant vitals; orthostatics if indicated; assistive device use; general mobility observations]

Positional Testing: (Document observed nystagmus pattern—do not summarize as simply "positive" or "negative." If a test was not performed, briefly note why.)

• Dix-Hallpike Right:
  • Nystagmus: [torsional upbeating / torsional downbeating / horizontal / none]; Latency: [seconds]; Duration: [seconds / persistent]; Reversal on sit: [yes / no]
  • Symptoms: Vertigo [yes / no]; Intensity [none / mild / moderate / severe]
  • [Additional notes if applicable, e.g., cervical limitation, not performed due to contraindication]
• Dix-Hallpike Left:
  • Nystagmus: [torsional upbeating / torsional downbeating / horizontal / none]; Latency: [seconds]; Duration: [seconds / persistent]; Reversal on sit: [yes / no]
  • Symptoms: Vertigo [yes / no]; Intensity [none / mild / moderate / severe]
  • [Additional notes if applicable]
• Supine Roll Test Right:
  • Nystagmus: [horizontal geotropic / horizontal ageotropic / none]; Latency: [seconds]; Duration: [seconds / persistent]
  • Symptoms: Vertigo [yes / no]; Intensity [none / mild / moderate / severe]
  • [Additional notes if applicable]
• Supine Roll Test Left:
  • Nystagmus: [horizontal geotropic / horizontal ageotropic / none]; Latency: [seconds]; Duration: [seconds / persistent]
  • Symptoms: Vertigo [yes / no]; Intensity [none / mild / moderate / severe]
  • [Additional notes if applicable]
• Other Positional Tests: [Test name, side, observed nystagmus pattern and symptom response] (Include only if performed.)

Oculomotor/Neurologic Screen: [Spontaneous nystagmus; gaze-evoked nystagmus; pursuit/saccades; head impulse test findings; other neurologic signs] (Include only when presentation is atypical, unclear, or red flags present; otherwise omit entirely.)

Assessment

[Clinical synthesis linking findings to diagnosis: state determination as definite BPPV / suspected BPPV / positional vertigo not consistent with BPPV; include canal and side only when supported by observed nystagmus pattern with explicit linkage to findings; note atypical or central features and referral decision if applicable] (If canal/side cannot be determined, state "canal/side not yet confirmed.")

Interventions

(Include this section only if treatment was performed today.)

• Canalith Repositioning: [Maneuver name (Epley / Semont / BBQ roll / Gufoni / other)]; Target: [canal and side]; Repetitions: [number]; Response during maneuver: [nystagmus observed, symptom intensity, adverse events]; Post-maneuver status: [symptom change and tolerance]
• Vestibular Rehabilitation Exercises: [Gaze stabilization / habituation / balance training with dosage parameters] (Include only if provided.)
• Patient Education: [Explanation of findings; safety and fall risk counseling; recurrence expectations; when to seek urgent care; home program or written instructions provided: yes / no]

Plan

• Follow-up: [Timing for reassessment; visit frequency and duration if ongoing care]
• Reassessment plan: [Repeat positional testing / symptom tracking / outcome measures]
• Functional goals: [Measurable goals with timeframe]
• Coordination: [Communication with referring provider; ENT or Neurology referral if indicated]
• Post-maneuver guidance: No routine postural restrictions recommended per current guidelines; [patient-specific safety precautions if any]

Signature: [Clinician name, credentials] — [Date/Time signed]