Now Offering: Mobile Rehabilitation Services!

Rehab Initial Evaluation Questionnaire

Client Name *

First

Last

Client Phone Number *

Client Email *

Client Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient Name *

Primary Veterinarian *

What medications and supplements is your pet on (include any joint supplements)? *

Current diet and appetite. Please note any allergies or food sensitives *

Presenting problem/surgery performed and date performed *

Do you have any concerns about your pet’s recovery/current state so far?

Is your pet able to squat/lift leg normally to urinate or defecate? *

Current activity level (i.e. leashed walks for potty breaks outside, daily walks, etc.) and prior activity level, before injury/surgery? *

Describe your pet’s environment? (Type of floors, stairs, furniture they climb on, fenced yard, access to dog door, etc.) *

On a scale of 0-4 how much pain is your pet in?

Selected Value: 0

What painful behaviors are you seeing (such as crying when rising, appearing stiff when moving, licking, panting, etc.)? *

What are your specific goals for your pet (some examples may include hiking, swimming, sports, or just able to achieve daily walks comfortably)? *

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