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BCM - Baylor College of Medicine

Giving life to possible

Center for Balance Disorders

Forms and Pretest Instructions

Forms are available in both English and Spanish for patients coming to the Center for Balance Disorders. These may be filled out prior to an appointment and can be read and printed.

Tenemos formas medicos para los pacientes del Center for Balance Disorders para llenar antes de la cita. Si usted gusta llenar las formas medicas antes de la cita, puede obtenerlas en la siguente dirrecciòn electronicas.

Pretest Instructions - a list of what to do in preparation for taking the ENG, or balance test, and what medications to avoid prior to testing. When in doubt, please call your physician.

Instrucciones prévias al Examen - una lista de preparativos y los medicamentos que debe evitar antes del examen ENG (examen de la systema de balancia). Si tiene duda, por favor llame a su doctor.

Medical Questionnaire - questions regarding the patient's medical history for the laboratory. They can be filled out prior to coming to save time. We have more forms at the Center if you forget.

Cuestionario Médico - para ahorrar tiempor, puede contestar preguntas sobre la historia médica del paciente. Tenemos más formas en la clínica si lo olvida.

Authorization for Release of Protected Health Information - this form instructs and allows the laboratory to send copies of the testing or rehabilitation report to the doctor(s) of choice.

Autorización para Divulgación de Información Medica - esta forma manda y da permiso a nuestro laboratorio para mandar los resultados de los examines a doctores diversos.

Visit Form - this form contains pertinent information such as address, birthdate, etc., of the patient. It should be updated with each visit.