Optimum Health and Wellness

Diagnostic Testing Screening Tool

Patient Name: Date: April 22, 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: 52061911e6d77adc6e990d6a67619e09f99e1797
Timestamp Audit
January 24, 2020 4:44 pm AKDTDiagnostic Testing Screening Tool Uploaded by Optimum Health and Wellness - emily@ohwpt.com IP
June 8, 2020 3:30 pm AKDTNikki Brown - nikki@ohwpt.com added by Christopher Comstock - emily@ohwpt.com as a CC'd Recipient Ip: