Optimum Health and Wellness

Diagnostic Testing Screening Tool


Patient Name: Date: July 24, 2021

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:


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

Leave this empty:

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Signature Certificate
Document name: Diagnostic Testing Screening Tool
lock iconUnique Document ID: 9b663c57549808802996e1c731bf55c61fa53c42
Timestamp Audit
January 24, 2020 4:44 pm AKDTDiagnostic Testing Screening Tool Uploaded by Optimum Health and Wellness - nikki@ohwpt.com IP 206.223.197.206
June 8, 2020 3:30 pm AKDTNikki Brown - nikki@ohwpt.com added by Christopher Comstock - emily@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206
July 1, 2021 4:32 pm AKDTStephanie Cain - stephanie@ohwpt.com added by Optimum Health and Wellness - nikki@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206
July 9, 2021 5:07 pm AKDTElizabeth McCallister - elizabeth@ohwpt.com added by Optimum Health and Wellness - nikki@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206