New Patient Questionnaire
Thank you for your interest in Canine Physical Rehabilitation, Fitness or Cannabis counseling! 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.
Sign in to Google to save your progress. Learn more
Email *
What appointment type are you inquiring about? *
What is your First Name - Last Name *
This will help us request records from your regular veterinarian
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 Pet's Name *
Pet's Gender *
Pet's Species *
Pet's Breed *
Pet's Birthdate (approximately) *
MM
/
DD
/
YYYY
Has your pet had any diagnostics performed within the past year that may affect health? *
Diagnostics include ultrasounds, radiographs, bloodwork, etc. This is very important for harm reduction education for pet parents.
How has your pet been feeling lately? *
Any changes in energy? Any coughing, vomiting, diarrhea, decreased appetite, pain, etc.?
Is your pet currently recovering from a medical procedure or have had a medical procedure in the last year? *
If you responded yes for recovery from a medical procedure, please describe below.
Examples: Knee surgery, Back surgery
If you responded No:  Please describe what services you are looking for.
Examples: Fitness and Conditioning, Posture or Movement evaluation, Cannabis counseling
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
Please list any supplements that your pet is currently taking. *
This should include any supplements (like fish oils, hemp products, glucosamine) that can be purchased over the counter.
Does your pet have any food allergies or dietary restrictions? Please indicate which diet your pet is on. *
Please include brand name, kibble/canned, amount and frequency allergies to certain proteins or grains, etc.
Please describe your pets normal routine of activity *
Examples: walk length or duration, frequency of walks, likes to go hiking, etc.
What is your home environment like? *
Please check all that apply. If your pet has difficulty navigating any of these things please check "Other"
Required
If you answered "Other" to the previous question, please describe challenges or disability your pet is having at home.
What other pets do you have at home?
Please include species and age.
If the previous question was answered, please indicate whether or not interactions have changed lately.
Examples include: "My pet is getting less tolerant of the other pet", "My pet wants more alone time"
What are your goals and expectations of this appointment? *
Examples include pain management, increase fitness, surgical recovery, movement evaluation etc.
Do you have Pet Insurance? If so please indicate below. *
Some insurance carriers cover rehabilitation therapies. We encourage you to contact your policy holder prior to a visit.
Do you have any financial, distance or time commitment concerns? *
We only ask this question to help determine individual families' needs.
How did you hear about us? *
In the space below, please include any other information that was not addressed in the questions above.
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms