Veterinary Rehabilitation - New Patient Questionnaire
Owner and Pet Details
Owner name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best contact number for day of appointment
*
Pet’s name
*
Breed
Age
Sex
Weight
Medical History and Current Concerns
Main area(s) of concern
*
Veterinary diagnosis
Other previous issues/surgery
Pet’s favourite treat
Does your pet have any food allergies?
*
Current medications - List dose and frequency *please give as normal even on appointment day
*
Does your pet need pre visit sedatives? - List dose *please arrange with your vet prior to this visit
*
Dietary/joint supplements - List
*
Any adverse reactions to previous medications?
*
When did the problem first occur?
How has it progressed or changed?
Diagnostic tests or treatments performed
Does your pet have any activity restrictions? (e.g. crated, toilets walks only etc.)
Mobility and Daily Routine
If your pet is still being walked - for how long and how often?
Does your pet use stairs at home? How many, and are they inside or outside?
Is the problem worse at a time of day?
Please Select
morning
night
same
neither
unsure
Is the problem worse after rest?
Please Select
yes
no
same
unsure
Is the problem worse after exercise?
Please Select
yes
no
same
unsure
n/a
Where does your pet sit in the car? Are they able to jump in on their own?
What type of flooring does your pet use at home?
Does your pet get along with other dogs?
How does your pet usually respond at the vet? e.g. do they need to be muzzled for exams? (We are Fear-Free and Low Stress certified, please let us know if your pet needs additional considerations)
*
Is there anywhere your pet does not like to be touched?
*
What commands or tricks does your pet know? (e.g. sit, drop)
What would you like your pet to achieve with rehabilitation?
How much time can you spend doing therapeutic exercises with your pet 3-5 days a week?
Is there anything else you would like us to know about your pet?
Consent and Sign-off
Cost of initial Rehabilitation Assessment is $450 excluding medication/devices as indicated and discussed at discharge.
I authorise Veterinary Rehabilitation Services to perform a veterinary rehabilitation examination and initial treatment of my pet. I have notified the staff of any concerns relating to the treatments/procedures being performed. At the time of admission I will be made aware of any risks involved and release the veterinarian and hospital from any legal and financial responsibilities arising from complications associated with the treatment. I understand that treatments can involve the use of TENS/EMS, laser, PEMF, manual therapies and/or therapeutic exercises and agree to have them applied as determined appropriate.
*
I agree
I authorise my pet’s photos/videos and basic details to be shared on social media/advertising
*
Yes
No
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