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Rehab Follow-up Session Questionnaire

Rehab Follow-up Session Questionnaire

Please fill out the following form at least 24-hours before your pet’s rehab appointment. Please note that this form is intended for established patients only.

Your name(Required)

Patient name(Required)

Date

MM slash DD slash YYYY

Function

How did they do after their last visit?(Required)

If sore, painful, weak, or other, explain:

2. Has there been any change in function since their last visit?(Required)

Yes

No

If yes, explain:

Pain

On a scale of 1-10, please indicate where you think their pain level is TODAY

Home Exercise Plan

How long and how frequent are your leashed walks?

Length (minutes)

Frequency per day

What other exercises are you doing at home? Please mark all that apply.

Sit to stands

Hip flops

Sit & shake

Massage

Ice

Heat

Posture therapy in stand

Cavaletti rails

PROM

Posture therapy in sit

Figure 8’s

Other

Sit to stands reps

Hip flops reps

Sit & shake reps

If other, please describe:

Is your pet allowed:

Run and play off leash?(Required)

Yes

No

N/A

On off/furniture?(Required)

Yes

No

N/A

Up/down stairs?(Required)

Yes

No

N/A

How do they do after the exercises at home?(Required)

If sore, painful, weak, or other, explain:

Do you think they could be doing more?

Yes

No

Unsure

If yes, explain:

Medications

Have there been any changes in medications (a new addition, dosage, or frequency) since your last visit?

Yes

No

If yes, explain:

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