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Rehabilitation Form
Help us get to know you and your pet!

Client Info

Client First Name

Client Email

Client Last Name

Client Phone Number

(Home exercises and progress notes will be sent through email)

Client Address

Preferred Method of Contact

Phone

Email

Additional contact you wish to have on your file. Please inclue name, phone number, and relationship to you.

Patient Info

Patient Name

Age

Patient Date of Birth

Sex

Male

Male Neutered

Female

Female Spayed

Species

Dog

Cat

Other

Breed

Colour

Pet Insurance Provider

Pet Insurance Number

I give permission for my pet to be photographed and/or videoed for any lawful purposes, including publicity, illustration, advertising and website content. *

Yes

No

Patient History

Major Problem

Referring Veterinarian

Surgical Procedure & Date

Surgeon & Clinic

History of present illness

Please list any medications your pet is on. Please include the dose.

Treatment since injury/surgery

Please list any supplements your pet is on. Please include the brand & dose.

Previous Medical History

Vaccine History

Does you pet have any known allergies?

If there are food allergies, please bring in a small bag of their food to be used as treats.

What do you feed your pet?

Kibble/Dry

Canned/Wet

Commercial Raw

Homemade Raw

Freeze Dried Raw

Homemade Cooked

Gently Cooked

Other

Pet Food Brand

Pet Food Formula

Treats

Current Excercise Routine

Please list & discribe any tricks or commands your dog knows

Please select all that apply to your pets tempermant.

Human Reactive

Dog Reactive

Anxious/Nervous

Unsure of New People

Needs Space

Friendly

Calm

Excitable

Food Motivated

Toy Motivated

Other

Working dog?

Yes

No

Other History

If your pet has and behavioural problems please describe what they are and any triggers

Activity Level

Sedentary - Spends most of the day indoors/little to no play

Low - Less than 1 hour of activity or play per day

Medium - 1-3 hours of activity or play per day

High - Over 3 hours of activity outside per day

Owners Goals

(ie. house pet / agility / sporting dog; what outcomes would you like to see from rehabilitation etc.)

(ie. injury / illness that limits ability to do at home exercises; time conflicts etc..)

Owner Constraints

Are there stairs in your home? (Approximate #)

Type of flooring in home? ie. hardwood

Are there any other pets in the home?

What kind of bed does your pet sleep on?

Activities of Daily Living

Please rank the below activities based on the following scale:
0 = unable to preform,
1 = needs moderate assistance,
2 = needs minimal assistance,
3 = able to perform independently

Posture to urinate

Posture to Defecate

Lay down to sit

Sit to stand

Roll over

Up stairs

Down stairs

Get in car

Get on couch/bed

Walk

Run

Jump

Duration of walk

Please only feed 1/2 of the normal amount of food the day of rehabilitation and bring the rest to be used as treats.

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Rehabilitation Form Help us get to know you and your pet!

Client Info

(Home exercises and progress notes will be sent through email)

Patient Info

Patient History

If there are food allergies, please bring in a small bag of their food to be used as treats.

(ie. house pet / agility / sporting dog; what outcomes would you like to see from rehabilitation etc.)

(ie. injury / illness that limits ability to do at home exercises; time conflicts etc..)

Activities of Daily Living

Please rank the below activities based on the following scale: 0 = unable to preform, 1 = needs moderate assistance, 2 = needs minimal assistance, 3 = able to perform independently

Please only feed 1/2 of the normal amount of food the day of rehabilitation and bring the rest to be used as treats.

Rehabilitation Form
Help us get to know you and your pet!

Please rank the below activities based on the following scale:
0 = unable to preform,
1 = needs moderate assistance,
2 = needs minimal assistance,
3 = able to perform independently