Clinic template

A Cliniko treatment note template for a vestibular physiotherapy assessment

This template scores the 25 item Dizziness Handicap Inventory, then runs through positional tests such as the Dix-Hallpike, an oculomotor screen, and a balance test battery, before the assessment and plan. It tests a symptom, dizziness, against a battery of provocation tests rather than a single body region, and is built as a Cliniko treatment note template.

Last checked 25 Sep 2026 against the sources listed at the end of this page.

Free template · Cliniko

Treatment note: initial assessment: vestibular physiotherapy

The template: 19 fields

Section	Field	Type	Notes
History	Dizziness description, in the patient's words	Paragraph	Cliniko type: Paragraph text. Ask the patient to describe the sensation rather than naming it dizziness or vertigo themselves.
History	Onset and triggers	Radio	Cliniko type: Multiple choice. Options: Positional (with head or body movement) / Spontaneous / Triggered by standing / Constant / Unknown.
History	Duration of typical episode	Radio	Options: Seconds / Minutes / Hours / Days / Constant.
History	Associated symptoms	Checkboxes	Options: Nausea / Vomiting / Hearing change / Tinnitus / Aural fullness / Headache / Visual disturbance / None.
History	Red flags screened	Checkboxes	Tick each one asked and cleared: Sudden severe headache / New neurological symptoms / Chest pain or palpitations / Recent head or neck trauma. Leave the default answer blank.
Questionnaire	Dizziness Handicap Inventory score	Text	Cliniko has no number type, so use Single line text. Record total out of 100, and physical, functional and emotional subscale scores if scored separately.
Oculomotor screen	Smooth pursuit and saccades	Paragraph	Normal or abnormal, with description of any nystagmus observed.
Oculomotor screen	Vestibulo-ocular reflex (head thrust test)	Radio	Options: Normal / Positive (catch up saccade) left / Positive right / Not performed.
Positional tests	Dix-Hallpike test	Paragraph	Result each side: nystagmus direction, latency, duration and symptom reproduction, or a note that the test was not performed and why.
Positional tests	Roll test	Paragraph	Result each side if performed, relevant to horizontal canal involvement.
Balance tests	Romberg and modified Romberg	Paragraph	Eyes open and closed, on firm and foam surface as relevant.
Balance tests	Functional gait or dynamic gait test result	Text	Name the test used and the score, for example Functional Gait Assessment.
Balance tests	Falls in the last 12 months	Text	Number and circumstances.
Assessment	Clinical impression	Paragraph	Working diagnosis, for example benign paroxysmal positional vertigo, vestibular hypofunction, or a note that findings are inconclusive and referral is needed.
Assessment	Onward referral needed	Radio	Options: Not required / ENT / Neurology / GP / Audiology.
Consent	Informed consent	Checkboxes	Options: Findings explained / Provocation tests may reproduce dizziness, this was explained / Treatment options explained / Consent given for assessment and treatment.
Plan	Treatment provided today	Paragraph	Repositioning manoeuvre performed and side, or vestibular rehabilitation exercises given.
Plan	Home exercise programme	Paragraph	Gaze stabilisation, habituation or balance exercises, as relevant.
Plan	Review date and re-scoring plan	Text	When the Dizziness Handicap Inventory will be repeated.

Build it in Cliniko

Go to Settings > Treatment note templates as an Administrator, click Add template and name it Vestibular assessment.
Add each section above with Add section, then set every question to one of Cliniko's six question types: Paragraph text, Single line text, Multiple choice, Checkboxes, Body chart or Date.
Warn patients before the appointment, and again in the consent section, that positional and provocation tests are expected to reproduce their dizziness briefly, since that reproduction is part of a positive test result rather than a sign something has gone wrong.
Type the Multiple choice and Checkboxes options exactly as listed in the note column so onset pattern and red flags stay consistent across the clinic's vestibular caseload.
Assign the template to your vestibular or dizziness initial consultation appointment type.
Run one test note recording a full Dix-Hallpike and Dizziness Handicap Inventory score on a test patient, save it as a PDF, and check the layout reads clearly before the whole clinic uses it.

AHPRA: The shared Code of conduct that the Physiotherapy Board of Australia applies asks for records that support informed consent and let another practitioner continue care. Because provocation tests are expected to briefly reproduce the patient's symptoms, this template puts that specific point in the consent section rather than leaving it as a general treatment risk.

A symptom battery, not a body region assessment

Vestibular assessment does not start from a joint or a muscle group, it starts from a symptom, dizziness, and works through a battery of specific tests designed to reproduce or rule out particular causes. This template mirrors that structure: history and red flags first, then a validated questionnaire score, then oculomotor and positional testing, then balance and gait. Each test has its own field because the pattern of results across the whole battery, not any single test, is usually what points to a diagnosis such as benign paroxysmal positional vertigo or vestibular hypofunction.

Why the questionnaire score gets one field, not a rebuilt instrument

The Dizziness Handicap Inventory is a 25 item questionnaire recording that goes here as a single score field rather than a rebuild of all 25 items inside Cliniko, in keeping with how the outcome measure fields work elsewhere in this cluster. Run the actual questionnaire on paper or a linked patient form, then record the total and subscale scores here so the same instrument can be repeated at review and the change tracked against a consistent number.

Consent has to cover what the tests actually feel like

Positional tests such as the Dix-Hallpike are meant to provoke the patient's dizziness briefly as part of a positive result, which is a different kind of discomfort to explain than the risk of soreness after a joint mobilisation. This template's consent section names that explicitly, so a patient is not caught off guard mid test and so the record shows they were told what a positive test would feel like before it was performed.

The onward referral field closes the same loop from the other direction. A vestibular battery is designed to rule things out as much as rule them in, and an inconclusive result with red flags cleared still needs a documented next step, whether that is ENT, neurology or simply a GP review, rather than being left as an open assessment with no plan attached.

Sources

The Dizziness Handicap Inventory is a 25 item questionnaire assessing the physical, functional and emotional impact of dizziness on daily life, scored from 0 to 100, and is used as an outcome measure in vestibular rehabilitation. Shirley Ryan AbilityLab, Rehabilitation Measures Database, checked 25 Sep 2026.
Cliniko treatment note templates support six question types (Paragraph text, Single line text, Multiple choice, Checkboxes, Body charts and Date), built under Settings > Treatment note templates and assignable to an appointment type. Cliniko Help, checked 25 Sep 2026.
Treatment note templates can be exported as a .json file by an Administrator and imported into another Cliniko account, or built from an uploaded JPG, PNG, WEBP or PDF up to 5MB. Cliniko Help, checked 25 Sep 2026.
The Physiotherapy Board of Australia applies the shared Code of conduct for registered health practitioners, which requires accurate records sufficient for another practitioner to continue care and to demonstrate informed consent. Physiotherapy Board of Australia, checked 25 Sep 2026.