THE CLINIC FOR NEUROLOGY, P.A.

1104 Monroe Street

Huntsville, Alabama 35801

Office: 256/533-4402

Fax: 256/551-1902

FALL PREVENTION AND BALANCE PROGRAM

Patient Name: _________________________________________________

Date of Birth: ______________________ Date: ____________________

Primary Diagnosis: _____________________________________________

Secondary Diagnosis:___________________________________________

Special Instructions: ____________________________________________

Physician Orders:

________ Videonystagmography

________ Physical Therapy Evaluate and Treat

Physician Signature: _______________________ Date: ______________