Rehab Service Consult Questionnaire

This form is for currently scheduled rehab patients. If you need to make an appointment, please contact us at 706-542-3221.

Pet's Name:*

Client's Name:*

Best Contact Number for You:*

Will someone other than you be picking up and/or dropping off your pet?*

Yes

Name:*

Phone Number:*

Please answer the following questions to the best of your ability regarding your pet's CURRENT function and/or post operation function.

What is the PRIMARY REASON for your consultation with our Rehab Service? Please provide information about when the issue started and if there has been any progression in symptoms.*

Any previous medical history we should be aware of? (i.e. cancer, surgeries, etc)

Yes

If yes, please explain:

Is your pet currently on any medication or supplements?

Yes

If yes, please list any CURRENT medications and supplements:*

Drug/Supplement

Amount

Frequency

What is your pet’s current diet? Please provide the brand, flavor, amount and frequency.*

Brand

Flavor

Amount

Frequency

What treats do you currently feed your pet? Please provide the brand, flavor, amount and frequency.*

Brand

Flavor

Amount

Frequency

Does your pet have any food allergies?*

Yes

If yes, please list what they are allergic to:

Is your pet free to have:

Does your pet eat from an elevated food and water dish?*

Yes

If yes, is the food/water dish at shoulder height to your pet?

Yes

What goals are you looking for in your pet’s rehab regimen?*

Current Activity

Current Activity (Please mark all that apply):

Leash Walks - How many minutes:

Leash Walks - How many times per day:

Potty Break Leash Walks - How many time per day:

Off Leash Exercise Outside - How many minutes:

Off Leash Exercise - How many times per day:

Crate Confined at Night - How long:

Crate Confined during Day - How long:

Other - Please describe:

Previous Activity

Activity prior to accident and/or injury

Previous Activity (Please mark all that apply):

Leash Walks - How many times per day:

Leash Walks - How many minutes:

Potty Break Leash Walks - How many time per day:

Off Leash Exercise Outside - How many minutes:

Off Leash Exercise - How many times per day:

Crate Confined at Night - How long:

Crate Confined at Day - How long:

Other - Please describe:

Home Atmosphere: please mark all that apply:*

If you selected other, please describe:

If your pet had surgery, how do you think they are recovering?

Slower than Expected

As Expected

Better than Expected

Do you feel that your pet is:*

Underweight

Overweight

Perfect Weight

Unsure

Does your pet still lower into a sit position?*

Yes

Is the sit normal?

Yes

On a scale of 1 to 10, with 1 being No Pain at all and 10 being the Worst Pain, where do you think your pet’s pain level is TODAY?*

Where do you think your pet’s pain level is at its WORST?*

Where do you think your pet’s pain level is at its BEST?*

Disclaimer: Your appointment will be performed by a registered veterinary technician who is certified in canine rehabilitation. This appointment was initiated by the referral from your veterinarian, but your animal will not be seen by a veterinarian through the rehab service.

Consent:*

I have read the above disclaimer and understand that I will not be seeing a licensed veterinarian today.

CAPTCHA

	Yes	No
Peanut Butter
Cheese
Treats

Current Activity

Previous Activity

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