CRCG Rehab Questionnaire

Please reply with answers to the following questions prior to your first appointment. Sending us this information prior to your appointment will allow more time dedicated to the exam, treatment planning, and answering any of your questions.

Owner Name*
First Last
Pet Name*
What presenting concern(s) do you have for your pet? Include dates of occurrence(s).*
Has/have the problem(s) progressed, stayed the same, improved or waxed and waned?*
Are there any medical history concerns such as illnesses, surgeries, injuries, or cancer?*
What diagnostics have been performed (radiographs, blood work, ultrasound, MRI, CT, etc)?*
Have any treatments been started or tried such as rehab, laser, acupuncture, or chiropractic therapy?*
What is your pet’s current activity level? Are there any activity restrictions? (Include daily activities such as walks, dog park visits, playing in the yard, etc.*
What is your pet’s prior activity level before the presenting complaint?*
What medications and/or supplements is your pet currently taking? Please include dosages and frequency.*
What is your pet’s diet?*
Does your pet have a good appetite?*
Does your pet have any allergies or food sensitivities?*
Does your pet have any difficulty urinating or defecating?*
Is your pet able to squat or lift leg normally to urinate and defecate?*
Does your pet exhibit any urinary or fecal incontinence? (any accidents without awareness)*
Describe the pain behaviors your pet exhibits. (crying, licking, panting, limping or restlessness)*
Does your pet’s pain or lameness change with weather, exercise, and/or rest? (describe changes)*
On a scale of 0-4, how painful is your pet? (0 = non-painful – 4 = most painful)*
- 0
- 1
- 2
- 3
- 4
Have there been any changes in your pet’s mood or behavior?*
Describe your pet’s environment. (Type of floors, stairs, furniture they climb on, fenced yard, and/or dog door)*
What are your goals for your pet?*
Name
This field is for validation purposes and should be left unchanged.