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Rehabilitation Intake Form

First Name

*

Last Name

*

Contact Phone Number

*

Contact Email Address

*

Pet Name

*

Pet Birthdate

*

Pet Species

*

Pet Breed

*

Current Wt:

*

Chief Complaint:

*

Recent Diagnosis (if known):

*

Medications:

*

Supplements:

*

Current Diet (include amount per day and any extra treats):

*

Human Safety (are there any injuries or health concerns that may impact your ability to assist your pet’s rehabilitation therapy?):

*

Who is your family veterinarian?

*

Date of last Rabies?

*

Who referred you to our clinic?

*

Please complete the questions on this form pertaining to your pet’s comfort level and functional abilities. This will help us to monitor progress of your pet throughout the rehabilitation program.

Level of Comfort:

*

Level of Comfort:

A

No signs of pain during rest or activity

B

Mild intermittent limping or soreness, no disruptions of daily activity

C

Occasional limping or soreness, some disruptions of daily activity

D

Frequent soreness throughout the day, constant disruptions of daily activity

E

Inability to get comfortable during rest or during any daily activity

What is your pet’s favorite activity

*

Is she/he able to play comfortably?

*

Have you noticed a change in your pet’s desire for play?

*

Do you notice any limping, soreness or stiffness during or after play?

*

What time of day (if any) do you notice discomfort, stiffness or soreness in your pet?

*

Any changes in attitude/temperament? (please elaborate)

*

Comments or Concerns: (What have you noticed as a change in your pet?)

*

Functional Abilities: (circle on for each question)

Able to position to urinate or defecate?

*

Able to position to urinate or defecate?

A

easily and comfortably performs

B

minimal difficulty; activity is performed slower but able to perform independently

C

moderate difficult, need assistance at times, appears uncomfortable to perform

D

not able to perform this activity; needs assistance 100% of the time; appears very uncomfortable

E

N/A

Able to change positions from lying to sitting or vice versa?

*

Able to change positions from lying to sitting or vice versa?

A

easily and comfortably performs

B

minimal difficulty; activity is performed slower but able to perform independently

C

moderate difficult, need assistance at times, appears uncomfortable to perform

D

not able to perform this activity; needs assistance 100% of the time; appears very uncomfortable

E

N/A

Able to change position from sitting to standing or vice versa?

*

Able to change position from sitting to standing or vice versa?

A

easily and comfortably performs

B

minimal difficulty; activity is performed slower but able to perform independently

C

moderate difficult, need assistance at times, appears uncomfortable to perform

D

not able to perform this activity; needs assistance 100% of the time; appears very uncomfortable

E

N/A

Able to lay on his/her side, then change position?

*

Able to lay on his/her side, then change position?

A

easily and comfortably performs

B

minimal difficulty; activity is performed slower but able to perform independently

C

moderate difficult, need assistance at times, appears uncomfortable to perform

D

not able to perform this activity; needs assistance 100% of the time; appears very uncomfortable

E

N/A

Able to scratch behind ears?

*

Able to scratch behind ears?

A

easily and comfortably performs

B

minimal difficulty; activity is performed slower but able to perform independently

C

moderate difficult, need assistance at times, appears uncomfortable to perform

D

not able to perform this activity; needs assistance 100% of the time; appears very uncomfortable

E

N/A

Able to stretch while standing or laying?

*

Able to stretch while standing or laying?

A

easily and comfortably performs

B

minimal difficulty; activity is performed slower but able to perform independently

C

moderate difficult, need assistance at times, appears uncomfortable to perform

D

not able to perform this activity; needs assistance 100% of the time; appears very uncomfortable

E

N/A

Able to negotiate flooring throughout the home?

*

Able to negotiate flooring throughout the home?

A

easily and comfortably performs

B

minimal difficulty; activity is performed slower but able to perform independently

C

moderate difficult, need assistance at times, appears uncomfortable to perform

D

not able to perform this activity; needs assistance 100% of the time; appears very uncomfortable

E

N/A

Able to get in and out of the home?

*

Able to get in and out of the home?

A

easily and comfortably performs

B

minimal difficulty; activity is performed slower but able to perform independently

C

moderate difficult, need assistance at times, appears uncomfortable to perform

D

not able to perform this activity; needs assistance 100% of the time; appears very uncomfortable

E

N/A

Able to get on/off the couch or bed?

*

Able to get on/off the couch or bed?

A

easily and comfortably performs

B

minimal difficulty; activity is performed slower but able to perform independently

C

moderate difficult, need assistance at times, appears uncomfortable to perform

D

not able to perform this activity; needs assistance 100% of the time; appears very uncomfortable

E

N/A

Able to get in and out of the car?

*

Able to get in and out of the car?

A

easily and comfortably performs

B

minimal difficulty; activity is performed slower but able to perform independently

C

moderate difficult, need assistance at times, appears uncomfortable to perform

D

not able to perform this activity; needs assistance 100% of the time; appears very uncomfortable

E

N/A

Able to go upstairs?

*

Able to go upstairs?

A

easily and comfortably performs

B

minimal difficulty; activity is performed slower but able to perform independently

C

moderate difficult, need assistance at times, appears uncomfortable to perform

D

not able to perform this activity; needs assistance 100% of the time; appears very uncomfortable

E

N/A

Able to go down stairs?

*

Able to go down stairs?

A

easily and comfortably performs

B

minimal difficulty; activity is performed slower but able to perform independently

C

moderate difficult, need assistance at times, appears uncomfortable to perform

D

not able to perform this activity; needs assistance 100% of the time; appears very uncomfortable

E

N/A

Able to run?

*

Able to run?

A

easily and comfortably performs

B

minimal difficulty; activity is performed slower but able to perform independently

C

moderate difficult, need assistance at times, appears uncomfortable to perform

D

not able to perform this activity; needs assistance 100% of the time; appears very uncomfortable

E

N/A

Able to jump?

*

Able to jump?

A

easily and comfortably performs

B

minimal difficulty; activity is performed slower but able to perform independently

C

moderate difficult, need assistance at times, appears uncomfortable to perform

D

not able to perform this activity; needs assistance 100% of the time; appears very uncomfortable

E

N/A

Able to stand while eating?

*

Able to stand while eating?

A

easily and comfortably performs

B

minimal difficulty; activity is performed slower but able to perform independently

C

moderate difficult, need assistance at times, appears uncomfortable to perform

D

not able to perform this activity; needs assistance 100% of the time; appears very uncomfortable

E

N/A