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Diagnostic Testing Screening Tool

Patient Name: Date: September 13, 2024

Dear Patient:

If you currently feel or have felt any of the following symptoms within the past month or if you have been diagnosed with any of the following conditions, please check the appropriate boxes.

This is a screening tool that can help your therapist determine what diagnostic tests* might be appropriate for you.

Please check all that apply:

Low Back and Radiating Pain

Numbness, Tingling, or Burning Sensation in the Legs or Feet

Weakness in Legs or Arms

You have Diabetes or Neuropathy

Thyroid Dysfunction

Tendinitis / Bursitis / Arthritis

Elbow Pain or Instability

Hip or Knee Pain or Instability

Blurred Vision

Dizziness or Vertigo

Unsteady gait/walking

Hypertension (High Blood Pressure)

Neck Pain and Radiating Pain

Numbness, Tingling, or Burning Sensation in the Arms or Hands

Loss of Sensation in the Hands or Feet

Daily alcohol 3 glasses or more

Muscle Disease / Muscle Cramping

Shoulder Pain or Instability

Wrist or Hand Pain or Instability

Ankle or Foot Pain or Instability

Hearing Problems

Headaches

History of falls due to dizziness

Hypotension (Low Blood Pressure)

*Electromyography/Nerve Conduction Studies, Autonomic System Testing, Somatosensory Evoked Potentials, Auditory & Visual Evoked Potentials, Musculoskeletal Ultrasound, Vestibular Testing.

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Timestamp

Audit

January 24, 2020 4:44 pm AKDT

Diagnostic Testing Screening Tool Uploaded by Jaimee Watson - jaimee@ohwpt.com IP 206.223.197.206

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