Labyrinthitis Discharge Instructions Form
Complete this form to document discharge details, current recovery status, instructions reviewed, follow-up timing, and acknowledgement of labyrinthitis care instructions.
Patient and Discharge Details
Patient Name
*
First Name
Last Name
Date of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Contact Method or Phone Number for Follow-Up
*
Condition and Recovery Status
Current recovery symptoms
*
Dizziness
Vertigo
Nausea
Vomiting
Imbalance
Hearing changes
Other
Overall improvement since treatment
*
Much improved
Somewhat improved
No change
Worse
Not sure
Discharge Instructions and Follow-Up
Prescribed Medications / Instructions Received
*
Activity and Safety Restrictions Acknowledged
*
No driving
No operating machinery
Limit work/activity
Fall-risk precautions
Use assistance when walking
Other
Home Care Instructions Followed
Rest at home
Hydrate well
Take medications as directed
Avoid alcohol
Use prescribed aids/support
Other
Follow-Up Appointment Date or Timeframe
*
Warning Signs Reviewed
*
Worsening dizziness
Severe headache
Persistent vomiting
New hearing loss
Fever
Trouble walking
Confusion
Other
Acknowledgement of Discharge Instructions
*
I received and understand the discharge instructions
Submit
Should be Empty: