Pre-Rehab Questionnaire If you are a pet owner and have a scheduled Rehab Evaluation appointment, please fill out this form: Pre-Rehab Questionnaire InstagramThis field is for validation purposes and should be left unchanged.Date MM slash DD slash YYYY Client Name* First Last Client Email*Client Phone*Pet's Name*What is the primary reason for your evaluation with our Rehabilitation team? Please provide information about when the issue started and if there has been any progression in symptoms.*Is there any previous medical history we should be aware of? (i.e. cancer, surgeries, etc.)*Is your pet currently on any medication or supplements?*What are your goals for your pet's rehabilitation program?*Current Activity Level* Leash Walks Potty Breaks - Leash Walk Only Free Roam Inside Travels up and down stairs Climbs on/off furniture Plays with toys or other pets Off-leash exercise outside Crate-confined at night Crate-confined during day/when supervised Other Activity Level Prior to Accident/Injury (skip if not applicable) Leash Walks Potty Breaks - Leash Walk Only Free Roam Inside Travels up and down stairs Climbs on/off furniture Plays with toys or other pets Off-leash exercise outside Crate-confined at night Crate-confined during day/when supervised Other If your pet had surgery, how do you think they are recovering? Slower than expected As expected Better than expected On a scale of 1 to 10, with 1 being No Pain At All and 10 being the Worst Pain, what do you think your pet's pain level is TODAY?*Please enter a number from 1 to 10.What do you think your pet's pain level is at its WORST?*Please enter a number from 1 to 10.What do you think your pet's pain level is at its BEST?*Please enter a number from 1 to 10.What is your pet's current diet? Please include the Brand, Flavor, Amount, and Frequency.*What treats do you currently feed your pet? Please include the Brand, Flavor, Amount, and Frequency.*Does your pet have any food allergies?* Yes No Is your pet free to have:* Peanut butter? Cheese? Treats? Do you feel that your pet is:* Underweight Overweight Perfect Weight Unsure CAPTCHA
