Rehabilitation Consultation Questionnaire

Name: Rouse Hill Family Veterinarian
Address: 10/591 Withers Road, Rouse Hill, NSW, 2155, Australia
Telephone: 02 9086 9130
Price range: $

Get started

Please fill out this form as completely and accurately as possible in order for us to get to know you and your pet. If you have questions, don’t hesitate to give us a call at 02-9086-9130.

Client Details

Client Name *

First

Last

Email *

Phone *

Patient Details

Name *

Age/Date of Birth *

Breed *

Sex *

Weight *

Primary Care Veterinarian (Please list your primary vet clinic’s name, doctor’s name & phone number): *

Do you have pet insurance? *

Reason for Appointment

Primary compliant *

Duration of problem *

Do you feel the problem has gotten… *

Better
Worse
Comes and goes
Stayed the same
Other

If Other

Has any testing been done in the last 12 months? This includes radiographs, x/rays, bloodwork, CT scan, MRI, ultrasound etc. Please have your vet send us these results.

What treatments has your pet had for this condition in the past? - List surgeries, physical therapies and medications names if appropriate.

Did you feel there was improvement with the above treatments?

History: General Questions

Diet and Amount Fed

Please list the specific brand, dry/canned as well as any treats regularly given *

How is your pet’s appetite? *

Does your pet have any food allergies? (If yes, please list) *

How is your pet’s water intake? (Choose all that apply) *

Normal
Increased
Decreased
Frequent Small Sips
Large Amounts At One Time

Your pet’s urination is… (Choose all that apply) *

Normal
Increased
Decreased
Incontinent
Straining/vocalising

The urine appears… (Choose all that apply) *

Normal
Clear
Dark
Bloody
Large volumes
Small volumes

Your pet’s stools are… (Choose all that apply) *

Normal
Increased
Decreased
Diarrhoea
Blood/Mucous in Stools
Incontinent
Excess Gas

Has your pet’s voice or noises that he/she makes changed at all? If yes, please describe: *

Your pet’s respiration/breathing is: *

Normal
Coughs
Has had a change in breathing

Describe any changes in breathing:

History: Mobility and Exercise Levels

Does you pet have problems with any of the following (Choose all that apply) *

Slippery Surfaces
Uneven Surfaces
Mild Inclines
Short Walks
Long Walks
Stairs
Posturing for Urination
Posturing for Defecation
Toileting Accidents
Difficulty Sitting
Difficulty Standing
Difficulty Rising from Sitting
Difficulty Walking
Limps During Walking
Painful or Lame Following Exercise
Other

If Other

Are the signs worse? (Choose all that apply) *

First Thing in the Morning
Late in the Day
During Activity
After Activity
After Rest
Same All the Time

Activity Level Prior to Injury: (Choose all that apply) *

Leash Walk
Leashed Jog/Run
Off Leash Park/Free Play
Activity Play (Ball, Frisbee etc)
Competitive Athlete (i.e. Agility, Flyball etc)
Working Dog (farm dog, police etc)

Are you currently restricting your pet’s activity? (Choose all that apply) *

Yes - Crate rest, leash walks only, etc
Yes - No high energy activities but otherwise normal
No
Pet self-restricts
Other

If Other

History: Pain and Behaviour

Does your pet seem painful? If yes, please grade (1 = mild to 10 = severe) and when. *

Does your pet stretch during the day? *

Has their stretch changed? Please describe. *

How is your pet’s energy level in general? *

Normal
Reduced
Increased

When is your pet’s energy level the highest? *

Morning
Afternoon
Night
Consistent

When is your pet’s attitude the best? *

Morning
Afternoon
Night
Consistent

How would you describe your pet’s personality? *

Outgoing
Shy
Aggressive
Content
Restless
Crabby
Depressed

How is your pet’s sleep schedule? *

Normal
Decreased
Increased
Restless at night
Has frequent dreaming/vocalisation/running in sleep

Please describe where your pet sleeps: *

Has your pet had any behavioural changes recently? If so, please describe. *

Have you noticed any irritability in your pet? If so, when and why? *

Has your pet ever demonstrated aggressive behaviour? When and why? *

Medical History

Current medications

Please list all prescribed and over the counter medications including the dosage and frequency given. *

Current dietary supplements and herbal therapies? *

Does your pet have any other medical history that has not already been discussed? (E.g. Seizures, heart condition, respiratory conditions, other previous surgeries?) *

Does your pet have any past history of cancer? *

Treatment Goals and Therapy

What specific goals are you seeking for your pet through rehabilitation therapy? *

Are you able/willing to do prescribed exercises at home as a part of your pet’s rehabilitation therapy? *

Home Environment: Choose all that apply (checklist) *

Other Animals
Short Flight of Stairs
Long Flights of Stairs
Primarily Carpet in Home
Primarily Tile/Hardwood/Vinyl in Home
More than 50% of their time is spent outside in the garden each day
More than 50% of their time is spent outside in the garden each day Sleeps on the Owner’s bed
Access to Dog Door During the Day
Access to Dog Door During the Night
Jumps Onto the Bed or Sofa
Young Children at Home
Free Access to the House at night
Small backyard
Large backyard

Authorisation

Social Media Release: I give permission for Rouse Hill Family Vets to post pictures or videos of my pet on their social media platforms (Facebook, Instagram, TikTok, YouTube and their website). *

Medical Record Release: Sometimes referring veterinarians, boarding facilities or groomers may request records to be emailed. We are asking at this time for your consent to do so if requested. *

I hereby aurthorise the veterinarian to examine, prescribe for, or treat the above-described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of service and that a deposit may be required for treatment. *

Clear Signature

Date *

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