Forms related to CDH

Unsurprisingly, we have quite a few forms.

Questionnaires for first visits to any of our doctors:

• Online questionnaire (preferred for all ) .
• Paper questionnaires (not so enthusiastic but we will deal with it) -- these are all PDF format. These can be faxed back to us. (312-3768707)
  • If you have mainly dizziness or a hearing problem, except for tinnitus, please fill out the dizzy questionnaire
  • If you mainly have tinnitus, use the tinnitus questionnaire.
  • If you have mainly headaches, please fill out the headache questionnaire
  • If you have something other than dizziness or headaches, please fill out the neurology questionnaire
• Extra (optional) online forms for conditions that have complex formal criteria:
  • If you may have PPPD, please fill out the PPPD checklist, print it out, and bring it in.
  • If you may have MdDS, please fill out the MdDS checklist, print it out, and bring it in.
  • If you may have Vestibular Migraine, please fill out the VM checklist, print it out, and bring it in.

Release forms: (optional)

• medical release "to" CDH form (pdf format) and send it to your doctor
• medical release "from" CDH form. If you would like us to send CDH records to someone else, get us this signed form. You can also handle this yourself by arranging for us to send you an encrypted medical record archive -- just send us a Mychart message and we will send you a password protected archive.

Consent forms -- most are optional (pdf format)

(We will ask you to sign to acknowledge that you read and consent at the time of your first visit. Copies are also available in the office)

• Consent for research (optional)
• Consent for telehealth (this is online) (required once for telehealth visits)

Legal disclosures and consent to care (pdf format) -- this is the fine print.

• Privacy practices
• Financial Policies

More information about what to expect at your visit can be found at the Appointment page.