Vestibular/Ocular Motor Screening (VOMS) Assessment Form

Vestibular/Ocular Motor Screening (VOMS) Assessment Form
Complete this screening form to record baseline symptoms, VOMS task responses, symptom provocation, and overall assessment notes.
Patient and Session Details
Patient Full Name
First NameLast Name
Date of Assessment
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Examiner / Clinician Name
Reason for Screening / Referral Context
Baseline Symptoms
Baseline Dizziness

0
1
2
3
4
5
6
7
8
9
10
0 is None, 10 is Severe
Baseline Headache

0
1
2
3
4
5
6
7
8
9
10
0 is None, 10 is Severe
Baseline Nausea

0
1
2
3
4
5
6
7
8
9
10
0 is None, 10 is Severe
Baseline Visual Discomfort

0
1
2
3
4
5
6
7
8
9
10
0 is None, 10 is Severe
Baseline Symptom Notes
VOMS Screening Items

Symptom Provocation by VOMS Task

Rows	Symptom Rating	Abnormalities
Smooth pursuits
Horizontal saccades
Vertical saccades
Near point convergence
Horizontal vestibulo-ocular reflex
Vertical vestibulo-ocular reflex
Visual motion sensitivity

Select theme: