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Vestibular Peripheral Function Test Summary

Right Ear

Non-specific

Left Ear

vHIT Lateral

Caloric

Rotary Chair Step Velocity

Rotary Chair SHA

VEMP

Key:

Clear response elicited, mostly intact function

Response elicited but not robust, in the abnormal range

Absent or very abnormal response

Did not test

How to use this form

Entering results

Click any result box to cycle through states:

  1. Empty / Did not test — no symbol, grayed out
  2. Check mark (green) — clear response, mostly intact function
  3. Tilde (amber) — response present but abnormal
  4. X (red) — absent or very abnormal response
  5. Click again to reset back to empty

Layout

Each row is one test. The left column is the right ear and the right column is the left ear. Rotary Chair SHA is a bilateral test and has only one box.

Key criteria

Once a test is marked as performed, the key at the bottom of the form automatically expands to show the numeric pass/fail criteria for that test.

Printing

Use your browser's print function (Ctrl/Cmd + P) to print or save as PDF. The form will print cleanly without this help button.