Patient Forms

We have made our Hearing and Balance Center forms available for downloading and printing here on our web site for your convenience. If you've been referred to the Hearing & Balance Center for testing, the following forms should be completed and brought to your first visit.

• Medical History Questionnaire
• Dizziness Handicap Index - if dizzy
• Activities-specific Balance Confidence (ABC) Scale - if balance has been affected

Although most patients feel well enough to drive after the evaluation, you may prefer having a driver if your symptoms have been severe in the past. If you have any questions while filling out these forms, contact the Hearing & Balance Center at 320-214-6997.

Additional Forms

• Release of Medical Records

Falls Prevention Test Foms

• Balance Self Test
• Sit to Stand Test

Diagnostic Testing Instructions

• ASU Pre-Test ENG/VNG Patient Instructions
• Computerized Dynamic Posturography (CDP)
• Settling Techniques

These forms are in an Adobe PDF format. If you don't have Adobe Acrobat Reader, you can download the free software using the link here.