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Best-Care-Rehabilitation-Questionnaire

1. Rehabilitation Questionnaire

Date *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Owner Name *This question is required.

Patient Name *This question is required.

Sex *This question is required.

Spayed/Neutered *This question is required.

Date of Birth/Approximate Age *This question is required.

Breed *This question is required.

Primary Care Veterinarian

Reason for Rehabilitation Referral

What is the history of your pet's injury/surgery, including how long ago you first noticed symptoms? *This question is required.

Is your pet being treated for any other medical conditions? (Diabetes, Cushings, Hypothyroidism, etc.) If so, what?

Please list any previous surgeries that your pet has had including dates:

Please list any prescribed medications, including over-the-counter medications such as vitamins that your pet takes:

Space Cell	Name of Drug	Strength	Frequency Given
Medication #1	Medication #1: Name of Drug	Medication #1: Strength	Medication #1: Frequency Given
Medication #2	Medication #2: Name of Drug	Medication #2: Strength	Medication #2: Frequency Given
Medication #3	Medication #3: Name of Drug	Medication #3: Strength	Medication #3: Frequency Given

Please list any allergies your pet has (food/medication/environmental):

Please list your pet's diet, including all snacks, bones, and goodies he/she enjoys in the day and the amounts:

Do you feel your pet is at a healthy weight?

What motivates your pet? (treats, toys, etc.)

What is your home environment like? Please check any/all that apply:

Stairs
Other Pets
Hardwood/Tile Floor
Fenced Yard
Small Children
Other: Please enter an 'other' value for this selection.

Is your dog crate trained?

Does your dog potty outside or on a potty pad?

Has your dog ever shown any aggression/fear towards people?

Has your dog ever shown any aggression/fear towards other dogs?

Please list any commands/tricks that your pet knows:

Please describe your dog's activity level prior to the most recent onset of symptoms:

What are your goals for rehabilitation?

How much time do you feel is realistic for you to commit to an at home exercise program with your pet per day?

Is there any other information you would like the rehabilitation team to know about your pet?