Physical Rehabilitation New Patient Questionnaire
Thank you for your interest in Canine Physical Rehabilitation at Windsor Animal Hospital! The information provided in this form is greatly appreciated and will expedite your consultation with us so we can spend more time with you and your pet.
Email address *
What is your First Name - Last Name *
This will help us request records from your regular veterinarian
Your answer
Your Pet's Name *
Your answer
How did you hear about us? *
What is the name of your regular veterinarian and the name and phone number of the hospital? *
We need this information to obtain your pet's medical history and to send records after the evaluation
Your answer
Have you had any diagnostics performed within the past year? *
Diagnostics include ultrasounds, radiographs, bloodwork, etc. Include the name of the hospital where these were done so we can call for records.
Your answer
Pet's Gender *
Pet's Species *
Pet's Breed *
Your answer
Pet's Coloring *
Your answer
Pet's Birthdate (approximately) *
How has your pet been feeling lately? *
Any coughing, vomiting, diarrhea, decreased appetite, pain, etc.
Your answer
Does your pet have a specific medical condition that you would like to address with rehab? *
Examples: degenerative myelopathy, intervertebral disc disease, osteoarthritis, etc.
Your answer
Is your pet recovering from a medical procedure? *
What is your pet's current activity level? *
Examples: walk length or duration, frequency of walks, etc.
Your answer
What is your home environment like? *
Please check all that apply.
What other pets do you have at home? *
Please include species and age.
Your answer
What food are you currently feeding your pet? *
Please include brand name, kibble/canned, amount and frequency
Your answer
Please list any medications (including strength and frequency it is given) that your pet is currently taking. *
This should only include medications requiring prescription from a veterinarian
Your answer
Please list any supplements that your pet is currently taking. *
This should include any supplements (like fish oils) that can be purchased over the counter.
Your answer
Are you interested in discussing supplements or nutrition/diet? *
Does your pet have any food allergies or dietary restrictions? *
Grain-free, raw diet, allergies to certain proteins, etc.
Your answer
What are your goals and expectations of rehab? *
Your answer
In the space below, please include any other information that was not addressed in the questions above.
Your answer
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service