New Patient Questionnaire
Owner's Name
*
First Name
Last Name
Pet's name
*
Date of Appointment:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Why are you bringing your pet for rehab therapy?
What problems or issues are you seeing?
*
When did the problem first arise?
*
Is it worse in the mornings or evening?
How has the problem developed since first noticed?
*
What are YOUR goals for your pet with physical rehabilitation?
*
Home Environment
What type of floors do you have?
*
Where does your pet sleep?
*
Do you have stairs in your home?
*
Yes
No
Does your pet have to use them daily?
Yes
No
What do you feed your pet and how much?
*
What treats does your pet like?
*
Be specific. All calories must be considered when defining a treatment plan.
Does your pet have any allergies?
*
Yes
No
What allergies does your pet have?
Do you take your pet for walks?
*
Yes
No
How long of a walk, and Is your pet walked on or off of a leash?
Do the noticed symptoms or lameness worsen after taking a walk?
Does your pet tire quickly or have to make many stops on walks?
Has your pet’s behavior changed with: (Please check all that apply)
*
Family member
Children
Other dogs
Going to the Vet
Visitors
People passing by the house
Loud Noises
Being Groomed/having nails trimmed
Strangers
Being left alone
Traffic
Physical Assessment
Please rate from 1 (with difficulty) to 5 (without difficulty)
How well is your pet able to position to urinate or defecate?
*
very difficult
1
2
3
4
without difficulty
5
1 is very difficult, 5 is without difficulty
How well is your pet able to transition from a lying positionto a standing position and vice versa?
*
very difficult
1
2
3
4
without difficulty
5
1 is very difficult, 5 is without difficulty
How well does your pet go up and down stairs?
*
very difficult
1
2
3
4
without difficulty
5
1 is very difficult, 5 is without difficulty
How well is your pet able to get in and out of the car?
*
very difficult
1
2
3
4
without difficulty
5
1 is very difficult, 5 is without difficulty
Is your pet able to get on/off the couch or bed without assistance?
*
very difficult
1
2
3
4
without difficulty
5
1 is very difficult, 5 is without difficulty
Is your pet able to run or jump?
*
very difficult
1
2
3
4
without difficulty
5
1 is very difficult, 5 is without difficulty
Medical History
Are you administering any medications or supplements (including aspirins and glucosamine supplements) at this time?
*
Yes
No
Please list the medications, dosages and how often they are given.
*
Have there been any previous diagnoses, surgeries or treatments?
*
Pain assessment
Using the pain scale below. Tell us your pet's degree of pain?
*
Score 0-10
Submit
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