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Acc Rehabilitation History Form -Form Fill

Q1

First Name
Q2

Last Name
Q3

Who is your pet's primary care veterinarian? Please list the veterinarian, clinic name and phone.
Q4

Do you have a secondary veterinarian that treats your pet? If so, please list the veterinarian, clinic name and phone.
Q5

Pet Name
Q6

What is the primary purpose of your visit? What are you most concerned about?
Q7

Are there any allergies or sensitivities to medications we should be aware of?
Q8

What are the specific symptoms/ailments or physical reasons you observe in your pet?
Q9

What are your goals for your pet to be able to do as a result of our time together? (i.e., reduce pain, recover from surgery, prevent surgery, improve performance in sporting dog events, etc.)
Q10

What is your dog's activity level in general?
Q11

What type of home does your pet currently live in?
Q12

What environmental conditions are a challenge for your dog:
Q13

How would you categorize your dog?
Q14

How do you exercise your dog?
Q15

What do you feed your dog? What are your pet's favorite snacks?
Q16

Please mark any of the following you observe. Provide notes if possible.
Q17

Does your pet have periodic diarrhea, vomiting or gastrointestinal distress?
Q18

Is there any history of seizures?
Q19

Does your pet get winded easily?
Q20

Does your pet have a heart murmur or other heart condition?
Q21

Does your pet get tired on walks?
Q22

Please note any health issues you not mentioned above that you feel would be important for us to be aware of.
Q23

Please note any diagnostics recently performed to assess your pet's condition and where they were performed.
Q24

Please list all current medications, including doses and frequency of administration. Sometimes pet parents put "See medical record" here. Please list the medications and how you are giving them even if they are referred to in the medical record(s).
Q25

Please list all current supplements including doses and frequency of administration.
Q26

Please describe any mobility issues you observe in your pet. Please note the affected area (i.e., back, front leg, right or left, etc.)
Q27

Has the frequency of changed over time?
Q28

Has the intensity changed over time?
Q29

What have you tried to this point to address your pet's condition?
Q30

Choose a number that best describes your pet's pain at its WORST in the last 7 days.
Q31

Choose a number that best describes your pet's pain at its LEAST in the last 7 days.
Q32

Choose a number that best describes your pet's pain at its AVERAGE in the last 7 days.
Q33

Choose a number that best describes your pet's pain as it is RIGHT NOW.
Q34

Description of Function:

Q35

General Activity
Q36

Enjoyment of Life
Q37

Ability to Rise to Standing from Lying Down
Q38

Ability to Walk
Q39

Ability to Run
Q40

Ability to Climb Stairs, Curbs, Doorsteps, etc.
Q41

Overall Impression: Choose the answer that best describes your pet's overall quality of life over the LAST 7 days.
Q42

Total CBPI Score
Q43

What treatments options are you interested in exploring
Q44

How did you hear about our service?
Q45

For Office Use only: Reference Limb