Pre-Rehab Questionnaire

Date

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*

Activity Level Prior to Accident/Injury (skip if not applicable)

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

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If you are a pet owner and have a scheduled Rehab Evaluation appointment, please fill out this form:

Pre-Rehab Questionnaire

Oak Hill Veterinary Care & Pet Resort

Daycare Hours:
Monday-Friday	7:00am – 6:00pm
Veterinary Hours:
Monday-Friday	8:00am - 5:00pm
Saturday	9:00am - 12:00pm


Saturday Pick Up:	9:00am - 10:00am
Sunday Pick Up:	5:00pm - 5:30pm