Diagnostic Testing Screening Tool
Patient Name: Date: July 24, 2021
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.
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Document Name: Diagnostic Testing Screening Tool
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