Animal Rehab Questionnaire Pet Parent Rehab Questions Fill out the questionnaire prior to your rehabilitation evaluation. Pet Owner's Name* First Last Your Email* Your Phone Number*Pet's Name*Pet's Primary Care Vet*Vet's Phone Number*Describe the current problem your pet is experiencing*How long has your pet been experiencing these concerns?*Do you believe your pet is in pain?*YesNoIf yes, select what they are exhibiting: Restlessness Limping Panting Licking Crying Have you noticed any improvements or worsening in condition since their last visit?Are there any other medical concerns to be aware of?*(Examples: history of seizures, heart conditions, past surgeries, etc.)Describe your pet's current activity level and/or restrictions:*Pet's Current Diet*Does your pet have any dietary restrictions?*YesNoIs your pet vomiting?*YesNoDoes your pet have diarrhea?*YesNoDoes your pet have full control of their bowels?*YesNoDoes your pet have full control of their bladder?*YesNoList any medications or supplements your pet is taking:What kind of flooring is in your home (check all that apply:) Hardwood Carpeting Area rugs Tile and/or stone Linoleum Does your home have stairs?*YesNoDo you have other pets in the home?*YesNoIf YES, list type and ages:What tasks does your pet need to perform at home?(Examples: going up/down stairs, jumping on/off furniture, chase squirrels, etc.)What are your expectations for rehabilitation? (check all that apply)* Pain free Walk unassisted Short walks Long walks If LONG WALKS was selected, how long?Sometimes the rehabilitation practitioner will provide instruction for at-home rehab exercises. Does your family have limitations which would prevent these exercises from being done?* No limitations Cannot physically participate Minor physical limitations Inflexible schedule Frequent travel What are your goals with rehabilitation?*Any additional information:
