Physical Rehabilitation Intake Form | Greenland Veterinary Hospital

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We are excited to see your pet for their initial rehab consult! Please fill out this form at least 24 hours prior to their initial appointment. By doing so, this will allow us more time at your visit to discuss any recommended rehab program, go over initial exercises, and answer questions. Some questions are marked as required. Others are optional but the more information we have, the better we will be able to tailor the rehab program to your pet's individual needs.

If your pet has had diagnostics or treatments for the presenting problem at hospitals other than Greenland Veterinary Hospital, please make sure to request that they send all relevant records (including x-rays and labwork) to us. If we have not received records at least 24hours in advance of the appointment, we will contact you to reschedule your appointment to a later date to allow time for these to be reviewed prior.

Name*

First Last

Email Address*

Best Contact Phone Number **

Pet's Name*

Breed

Age

Pet Weight (if known)

Gender

Male - not neutered

Male - neutered

Female - not spayed

Female - spayed

Has your pet ever been enrolled in physical rehabilitation before?*

Behavior/Anxiety - Our goal is to make rehab as fear-free and positive as possible for your pet. Please tell us any behavioral concerns or anxieties that you think we should know prior (e.g. dog reactive, sensitive to paws touched, etc). Write N/A if not applicable.*

If your pet usually gets anxiety meds (i.e. trazodone/gabapentin) before vet appointments, we do recommend giving these before the initial exam. If your pet has not had these, but you think they would benefit from meds, please give us a call to discuss.

Primary Concern - i.e. the main reason you are bringing your pet to rehab. Please provide diagnosis if available or primary symptom(s) if not. If no specific health concern, it is okay to write something like general health or fitness/conditioning.*

History of primary concern - please provide a brief summary of the approximate timeline (i.e. onset of symptoms, progression of symptoms, and response to treatments so far) of the current primary concern if applicable. Write N/A if not applicable.*

Type and date of surgeries. Write N/A if not applicable.*

Other conditions - Please list all current medical conditions and previous major medical conditions. Be brief. Write N/A if not applicable.*

Prescription medications - list names, dosages, frequency. Write none if none.*

Supplements/OTC medications - Please list all over-the-counter medications and supplements including names, dosages, frequency. Write none if none.*

Any medication allergies or adverse reactions to meds in the past? Please list name of med/supplement and reaction they had if known. Write none if none.*

Lifestyle/Diet

There is no wrong or right answer to these. Knowing your pet's normal lifestyle can help us design the best individualized rehab plan.

General activity level of your pet (this refers to normal activity prior to any current injury or surgery). Check all that apply.

Mostly sedentary and/or indoors

Indoors only but very active with toys and play

Plays with housemate(s)

Occasional leash walks

Leash walks daily or most days

Access to fenced in yard but no specific exercise outside

Regular off leash activity/play or long hikes

Sedentary during week but very active on weekends (i.e. "weekend warrior")

Sporting activities (e.g. flyball, agility, FastCat, etc)

Show pet

If sporting activity, please list what sport(s) and indicate if casual or competitive. Leave blank if does not apply.

Home Setup. Please check off any of the below that apply to your pet's home environment.

Full flights of stairs

Small flights of stairs (e.g. few stairs in out of house or small split entry)

Slippery floors in house (e.g. laminate, wood, vinyl etc)

Use traction assistance (runners, yoga mats, toe grips etc)

Jumps on/off furniture

Fenced in yard

Elevated bowls

Orthopedic bed

Full body or hind end harness used

Diet - indicate brand/flavor or if homemade, amount, and frequency per day.*

Does your pet get treats/table food? If weight loss is one of your goals, be very specific on type/brand, amount, and frequency.*

Current Restrictions/Rehab

This will mostly apply to pets in recovery from surgery or an injury. Can leave blank if this does not apply.

Is your pet currently under activity restriction?*

Yes

Please briefly describe degree of restriction (i.e. crate rest, no stairs or furniture, leash walks only etc) and roughly when the restriction began.

Are you doing prescribed leash walks?*

Yes

How long in minutes (estimate/average)?

How many times per day?

Are you doing any rehab exercises already?*

Yes

Provide name (or description) of exercise, repetitions, and frequency (e.g. PROM, stretching, weight shifting etc).

Rehab Goals

Knowing your pet's current challenges and your goals for rehab will help us design the best rehab plan to try to meet those goals.

Does your pet have difficulty with any of the following? Check all that apply. Check only if a challenge for them. Do not check if able to do them but currently under activity restriction recommendations not to.

Walking

Running/Off leash activity

Stairs - going up

Stairs- going down

Jumping up on furniture or into car

Jumping off furniture or out of car

Standing for long periods

Sitting or laying down

Rising from sit or down

Posturing to urinate or defecate

Eating/drinking from bowl on floor

Traction/sliding on floors

Scuffing/dragging of paws

Losing balance

Sport performance concern

None or Only because of current activity restrictions

Other

Are you concerned that your pet is in pain?

Yes but believe it is well controlled

Yes and would like to discus improving pain control

Not sure

What are your goals for rehab? This can be as specific (e.g be able to go up 5 steps into house, be able to go for off leash hikes, weight loss etc) or as general (e.g. improve overall mobility and comfort, optimize post-op recovery, improve sport performance etc) as you would like.*

Specific questions/topics to address: If there are any questions, concerns, or topics you would like to specifically discuss at your visit that you do not feel are covered in this form, please feel free to write them here.