Physical Rehabilitation Client History Questionnaire Form Physical Rehabilitation Client History Questionnaire Patient Name * Email * Date * Please provide a brief summary of the injury/issue your pet is coming to receive rehab for. The referring doctor will have sent referral forms but what is your perception? Include when symptoms started and how long they’ve been going on for. * Please list any medications you give and how often you give them. What food does your pet eat? Do they take any joint supplements? * How do you feel your pet is doing today in terms of mobility? If this is a return session, please include how they did after their last visit. Do you feel your pet is in any pain? Please rate it on a scale of 1 to 10 (10 being the most painful 1 being least painful) Prior to injury/illness what activities did your pet enjoy doing the most? Are these activities limited by your pet's injury/illness? * What are your goals for your pet going through physical rehabilitation? * We are very food motivated here! Is it okay for your pet to receive treats during their sessions? Please list any food allergies. * * Stars indicate questions you need to fill out if this is a first visit. If this is a returning session you only need to fill out questions without stars unless something has changed! Captcha Submit If you are human, leave this field blank.
