Rehabilitation Pre-Consultation Questionnaire Rehab Pre-Consult Form Date* Date Format: 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?*Have there been any changes or anything that makes it better or worse? If so, please explain:*Below is a list of activities. Please select the number that best suits your pet's ability to perform each activity. The description of each number is as follows: 1 = Able to complete activity independently without any assistance 2 = Able to complete activity with minor assistance 3 = Able to complete activity with major assistance 4 = Not able to complete activity with any type of assistance 5 = N/A - not allowed to perform this activityStand*Sit*Lay Down*Transition stand/sit/down*Position to urinate*Position to defecate*Ascend stairs*Descend stairs*Ability on/off furniture*Ability in/out of cars*Run*Jump*Roll Over*Scratch ears or head with hind feet*Shake their entire body*Ability to navigate on slippery floors*Wag their tail*Are there other pets in the home?*YesNoIf yes, please list other pets:Is your pet able to sleep through the night well?*YesNoWhere does s/he sleep?*Does your pet have a job? (e.g. agility, therapy/service, obedience, working etc.)*YesNoIf yes, please describe:Please describe a typical day for your pet:*From the time they wake up to the time they go to bed, including all activity, walks, play, yard-time, crate-time, daycare, travel etc.How is your pet's thirst? Please include if this has increased/decreased recently:*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. Have there been any changes in your pet's weight?*YesNoIf yes, please explain:Please list all current medications and supplements, and doses:* Does your pet have any trouble with bladder/bowel control?*What motivates your pet? (treats, toys, people)*Does your pet have any allergies?*YesNoIf yes, please list the allergies:Doe your pet have any fears or dislikes?*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:Has your pet received any type of rehabilitation or acupuncture services before?*YesNoWhat are your goals with providing rehabilitation for your pet?*Has your pet ever had any major illnesses, injuries, or surgeries?*YesNoIf yes, please list the illness, injury, or surgery:Has your pet had any imaging done (X-rays, MRI, CT U/S)?*YesNoIf yes, please list the imaging:
