Physical Therapy | Aqua Animal Care Center | Pet Rehabilitation

Rehabilitation Questionnaire

Please fill this out and submit prior to arriving for your appointment. Use your mouse or "tab" to move between answers.

This form is intended to establish your pet's medical history and assess your pet's functional abilities to help us monitor his/her progress. Completion of this form does not register you for an appointment. Please call the office to make an appointment.

Owner's First Name

Owner's Last Name

Pets Name

Pets Gender (male/female)

Pets Birthdate ( can be approx.)

Breed

What are your expectations?

Date of Injury (if any)

Date of Surgery (if any)

Pertinent Medical History

Current Medications & Supplements (please include dosage and frequency)

Does your pet use raised food & water bowls? (yes/no)

Please describe your pets diet, includiing how long he/she has been on this diet as well as amount/frequency

What kind of floors are in the house? (carpet/tile/hardwood/other?)

Do you have any stairs? If so, how many?

Do you have any other pets? What type and how many?

Does your pet use a ramp to get on/off elevated surfaces? (for example to get up on the couch/bed/car or other)

How long are your daily walks, what surfaces are being walked on, and how many times per day is your pet walked?

What was your pet's previous level of activity before injury? (if applicable)

Is your pet reactive towards other dogs?

Any other concerns you would like to discuss?

Please enter a number where you can be reached

Current Veterinarian and contact number

Please list any specialists seen and contact numbers (if applicable)

Thank you, we look forward to meeting you and your pet.