AAA PT PROVOKED VERTIGO TEST

Baseline Symptoms

	Comment	Intensity	Duration	Nystagmus	Score
1. Sitting -> head rotation
2. Sitting -> head flex. and ext.
3. Sitting -> supine
4. Supine -> left side
5. -> right sife
6. Supine -> sitting
7. Sitting -> nose to left knee
8. -> Sitting right ear on right shoulder
9. Sitting -> nose to right knee
10. -> Sitting left ear on left shoulder
11. Sit -> stand
12. Standing -> turn right 360 degree
13. Standing -> turn left 350 degree
14. Standing -> bend to floor left
15. -> standing
16. Standing -> bend to floor right
17. -> standing
18. Left Hallpike (modified/standard)
19. -> standing
20. Right Hallpike (modified/standard)
21. ->
22. Other

Intensity: Scale from 0-10 (0= no sx, 10= severe sx)
Duration: Scale from 0-3 (5-10 sec= 1, 11-30 sec= 2, >30 sec= 3)
Total # positive:*
Date*

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AAA Physical Therapy, LLC
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8975 Guilford Rd Ste 170 Columbia, MD 21046

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