Physical Rehabilitation Patient Questionnaire

Please complete this questionnaire prior to your Initial Evaluation.

Client Information
Client Name *
Client Name
Address
Address
Phone
Phone
Patient Information
Spayed/Neutered
Is your pet...
mark all that apply
Referring Veterinarian Information
Patient History
Does your pet enjoy treats and/or toys?
Lifestyle History
Is your pet able to go on a walk?
Do you notice problems during or after a walk? (lameness, stiffness)
Has your pet experienced an increase or decrease in weight?
Has your pet experienced an increase or decrease in endurance?
Have you noticed a change in your pet’s temperament/attitude?
FUNCTIONAL QUESTIONNAIRE
Survey
Survey
Strongly Disagree = not able to perform activity (needs assistance 100% of **time) Disagree = moderate assistance to perform activity (needs assistance greater than 50% of **time) neutral = minimal assistance to perform this activity (needs assistance less than 50% of **time) Agree = no assistance needed Strongly Agree = N/A
Able to position to urinate/defecate
Able to transfer from lay to sit
Able to transfer from sit to stand
Able to go up stairs
Able to go down stairs
Able to stand for 2-3 minutes
Able to get in and out of car
Able to get on/off couch or bed
Able to run
Able to jump
Able to walk on slippery surfaces