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Pre-Consult Form: Rehabilitation

Rehab Pre-Consult Form

"*" indicates required fields

Date*

MM slash DD slash YYYY

Client Name*

First Last

Patient Name*

First Last

Email*

What are your main concerns regarding your pet:*

How long has this been occurring?*

Is there anything that makes it better or worse? If so, please explain:*

Does your pet have trouble with any of the following activities?

Standing*

Yes

If yes, please explain:

Sitting*

Yes

If yes, please explain:

Laying down*

Yes

If yes, please explain:

Transitioning between stand/sit/down*

Yes

If yes, please explain:

Posturing to urinate or defecate*

Yes

If yes, please explain:

Bladder/bowel control*

Yes

If yes, please explain:

Ascending or descending stairs*

Yes

If yes, please explain:

Getting on/off furniture*

Yes

If yes, please explain:

Getting in/out of car*

Yes

If yes, please explain:

Running*

Yes

If yes, please explain:

Jumping*

Yes

If yes, please explain:

Navigating slippery floors*

Yes

If yes, please explain:

Wagging their tail*

Yes

If yes, please explain:

Is your pet able to sleep through the night well?*

Yes

Does your pet have a job? (e.g. agility, therapy/service, obedience, working etc.)*

Yes

If yes, please describe:

Please describe your pet's daily activities:*

Include walks (on or off leash) and duration, play, yard time, daycare, etc.

Please tell us what you feed your pet, including brand/variety of food, frequency and quantity. Please include treats and how many.*

For Example: Natural Balance, Limited Ingredient Diets Potato & Duck Dry Dog Formula. 1 cup, twice a day. 2 bully sticks a day.

Does your pet have any allergies?*

Yes

Have there been any changes in your pet's weight?*

Yes

If yes, please explain:

Please list all current supplements and doses:*

Please list all current or recent medications and doses:*

What motivates your pet? (treats, toys, people)*

Does your pet have any fears or dislikes?*

Has your pet ever had any major illnesses, injuries, or surgeries?*

Yes

If yes, please list the illness, injury, or surgery:

Has your pet had any imaging done (X-rays, MRI, CT U/S)?*

Yes

If yes, please list the imaging:

Has your pet received any type of rehabilitation or acupuncture services before?*

Yes

What are your goals with providing rehabilitation for your pet?*

Please list here any additional comments, concerns, quality of life:

Please provide any other additional information you think would be helpful for us to know about your pet:

Phone

This field is for validation purposes and should be left unchanged.

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