Rehabilitation Questionnaire

Thank you for choosing MobilityVet for your rehabilitation needs. To help us prepare ahead and tailor your visit specifically for you and your pet’s needs at the initial evaluation, we would appreciate it if you would take a few minutes to answer some important questions.

Client Information:

Client's Name(Required)

First Last

Mailing Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email:(Required)

Phone(Required)

How did you find us (google/client or vet referral)?(Required)

Preferred method of contact (email/text/phone):(Required)

From which veterinary clinic(s) may we request medical records?(Required)

Do you have a regular veterinarian you’d like us to share medical records with?(Required)

Do you have pet insurance? Which company? Is this condition covered?(Required)

Patient Information

Patient's Name(Required)

Patient's Species:(Required)

Dog

Cat

Patient’s Breed:(Required)

Patient's Date of Birth (or estimated age):(Required)

Patient’s sex? Spayed or Neutered?(Required)

Scheduling Preferences (scheduling is often complicated by the necessary commute between patients in a mobile practice, but we do our best to accommodate your schedule. Knowing your preferences will help us expedite the process when offering you options):(Required)

Medical History:

Does your pet have an occupation, sport or hobby?(Required)

What is your primary reason for seeing MobilityVet for a rehabilitation consultation? Are there any secondary reasons you’d like to share?(Required)

Please describe the onset and progression of each reason stated above. What interventions have helped? Are there any interventions that have not been helpful or caused adverse events or new problems?(Required)

Are there specific treatment modalities that MobilityVet offers that you are interested in? Are there any that you do not wish to have performed on your pet?(Required)

What supplements does your pet currently receive (such as joint supplements, vitamins, fish oils, etc. Please include brands, amounts, etc.)?(Required)

Product Name

Dose

Frequency

What medications does your pet receive? Please include all prescribed and routine meds such as heartworm preventative, flea/tick preventative, etc. Please include brand and dose.(Required)

Product Name

Dose

Frequency

Has your pet had any diagnostics done in the last 12 months? (Diagnostics include bloodwork, radiographs, ultrasound, MRI/CT, etc. Please include the name of the hospital where these were done so that we can call for records.):(Required)

What changes have you noticed in your pet’s activity level?(Required)

How painful do you perceive your pet to be?(Required)

Does your pet currently require assistance for normal activities? (walking, getting up, getting into the car, positioning for urination and/or defecation, etc.) Please explain as much as possible.(Required)

What is your pet’s current daily activity? (frequency and length of walks, etc.)(Required)

Does your pet have any food allergies?(Required)

Does your pet have any behavioral challenges we should be aware of? (anxious/fearful, shy, dog reactive, human reactive)(Required)

Does your pet have or have they been treated for, any other medical conditions?(Required)

What are your goals and expectations of rehabilitation therapy?(Required)

Home Environment:

What type of flooring do you have in your home?(Required)

Is your pet slipping or having trouble getting up on slick surfaces such as hardwood/tile?(Required)

Are there any stairs your pet must maneuver daily and, if so, does your pet have any difficulty with these?(Required)

Are there any other pets at home?(Required)

What does your pet eat? Please indicate brand and primary protein source (chicken, fish, beef, etc.), kibble vs canned, and the amount of food per day, including treats.(Required)

Rehabilitation is a team effort and prescribed home exercises, when performed regularly, contribute significantly to the patient’s outcome. How much time per week do you think you can commit to home care?(Required)

The finances of veterinary care are often a source of stress for pet owners. Talking about this openly can help us to develop a tailored plan for your pet that also meets your budget. Please share anything you feel might be helpful on this topic here, and we can also discuss any concerns at the time of consultation. The more we can understand your needs, the better we can serve you.(Required)

Is there anything else you would like us to know about your pet or home before our first visit?(Required)

Talent Release

MobilityVet often photographs and videos patients for the purposes of education, promotion or advertising. (please select one of the following):(Required)

I authorize the use of my pet’s image or likeness for these purposes

I do not authorize the use of my pet’s image or likeness for these purposes.

I authorize MobilityVet, Inc. to use and/or share my pet’s social media content.

Handle(Required)

Signature(Required)

Print Full Name:(Required)

Date(Required)

If there is anything that your pet is doing at home (such as walking differently, sitting funny etc.) which you believe would be helpful for us to view a video clip, please feel free to provide one! This is particularly helpful with cats and/or shy/fearful pets who may not be willing to exhibit their “normal” behavior in the hospital. You can email these to contactus@mobilityvetrehab.com

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