Rehab Form

This questionnaire is provided so that we gain a more comprehensive overview of your pet’s condition.

Date

Owner's First Name

Owner's Last Name

Pet's Name

Phone

Current diet

Favorite treats

Allergies

Rabies Vaccine Due Date - Rabies vaccine must be up to date by initial consult exam

Current medications and supplements (please include dose and frequency)

Referring Veterinarian

Referring Hospital

Presenting complaint

When was the problem first noticed

Your pet’s brief medical history (illnesses, injuries) – please include dates

Previous diagnostics performed (CT, MRI, X-rays, bloodwork, ultrasound)

Previous treatments and/or surgeries and dates – please include alternate modalities (chiropractic, acupuncture, etc)

Your pet’s activity

Prior to presenting complaint

Current daily activities (walks, dog parks, backyard):

Pain level on a scale of 0-4 (0-non painful, 4-most painful)

What pain behaviors do you notice (licking, panting, limping)

What is your rehab goal for your pet

How did you hear about our rehab program?

Friends/Family

Referred by Vet/Specialist

Social Media

Other

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By submitting this form I acknowledge and agree that Dr. Kristi Wubben is my pet’s rehabilitation specialist veterinarian and not their primary physician. Thus Dr. Wubben is not responsible for the medical needs of my pet outside of their specific rehabilitation noted in their record from the initial consult.

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Hours

Open 6 Days a Week

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Monday:08:00 am - 05:30 pm
Tuesday:08:00 am - 05:30 pm
Wednesday:08:00 am - 05:30 pm
Thursday:08:00 am - 05:30 pm
Friday:08:00 am - 05:30 pm
Saturday:08:00 am - 03:00 pm
Sunday:Closed

Rehab Form

Rehab Form

Your pet’s activity

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