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Rehabilitation Questionnaire

Name

First

Last

Phone

Email

Pet's Name

Breed

Age/DOB

What is the primary reason for your upcoming visit?

Has there been a change in your pet's daily activities such as their ability to get up from a laying position, participate in play time, or posture to go to the bathroom?

Do you have stairs in or outside of your home? Are they carpeted?

What types of flooring do you have in your home?

Is your pet currently on any prescription or over-the-counter medications or supplements? If so, please list medication name, dosage, and frequency

Does your pet utilize any special harness or sling to assist with mobility?

If you feel that a video or photo may be beneficial to help demonstrate your pet’s mobility concerns, you may send them via email, or bring them along to your consultation!

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