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:*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:Has your pet received any type of rehabilitation or acupuncture services before?*YesNoHow long have you had your pet?*Where did you acquire your pet?*Does your pet have any allergies?*YesNoIf yes, please list the allergies:What do you feed your pet? Please include brand/variety of food, frequency and quantity. Include treats, how many given and type if applicable.*For Example: Natural Balance, Limited Ingredient Diets Potato & Duck Dry Dog Formula. 1 cup, twice a day. 2 bully sticks a day. How is your pet's thirst? Please include if this has increased/decreased recently:*Has there been any changes in your pet's weight?*YesNoIf yes, please explain:Please list all current medications supplements and doses:* Do you travel with your pet?*YesNoIf yes, where and how often?Are there other pets in the home?*YesNoIf yes, please list other pets:Does your pet attend day care, dog parks, or boarding facilities?*YesNoIf yes, please describe the interaction and how often:Does your pet have a job? (e.g. agility, therapy/service, obedience, working etc.)*YesNoIf yes, please describe:Is your pet able to sleep through the night?*YesNoWhere does s/he sleep?*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, feeding etc.*What motivates your pet? (treats, toys, people)*Is your pet able to go for walks?*YesNoIf yes, what is the duration and frequency? Please describe your walks: frequent stops, continuous walking, environment, terrain etc.Have you noticed any changes in your pet's activity or energy levels?*YesNoIf yes, please explain:Do you feel as though your pet has a good quality of life?*YesNoI'm not sureBelow 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 between stand/sit/down*Position to urinate*Position to defecate*Ascent stairs*Descend stairs*Ability to get on/off furntiure*Ability to get in/out of cars*Run*Jump*Ability to navigate on slippery floors*Wag their tail*Please describe any other areas your pet has trouble with:Please provide any other additional information you think would be helpful for us to know about your pet:What are your goals with providing rehabilitation for your pet?*
