Patient and Owner Questionnaire

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Patient and Owner Pre-Assessment Questionnaire

Owner Details

Owner's Name *

Please enter your full name.

This field is required.

Owner's Phone Number *

Please enter your contact number.

This field is required.

Owner's Email Address *

Enter your email for correspondence.

This field is required.

Patient Details

Patient's Name *

What is your dog's name?

This field is required.

Patient's DOB *

When was your pet born, or what is your pet's current age?

This field is required.

Patient's Breed *

What breed is your dog?

This field is required.

Patient's Weight *

Enter your dog's current weight in kilograms.

This field is required.

Patient's Sex

What is your pet's sex and has your pet been desexed?

Female Entire

Male Entire

Female Desexed

Male Desexed

Patient's Age of Desexing

How old was your pet when he/she was desexed?

This field is required.

Patient's Vaccination Status

What is the pet's vaccination regime?

This field is required.

Patient's Allergies

Does your pet have any allergies that you are aware of?

This field is required.

Patient's Siblings

Do you have other pets at home, and if so, what type/breed and age?

This field is required.

Health Concerns/Conditions

List any previous surgeries, injuries or medical conditions your dog has.

Current Medications

List any medications your dog is currently taking, including name of the medication, dose given and how often per day.

Current Supplements

List any supplements your dog is given, including name of the supplement, dose given and how often per day.

Behavioral Issues

Describe any behavioral issues your dog may have.

Daily Exercise Routine

This may include length of walks in terms of time and distance, any sports your dog participates in, frequency of exercise, beach visits or hikes,...

Dietary Information

Describe your dog's average daily food intake, including treats.

Regular Veterinary Clinic

Do you have a regular vet or Veterinary Clinic that you see with your pet?

This field is required.

Incident Details

Primary Reason for Visit *

What is your main reason for seeking rehabilitation support for your pet?

This field is required.

Date of Injury/Diagnosis *

When was the injury/diagnosis made, or approximately when did you first notice signs of the issue developing?

This field is required.

History of the Issue *

This may include length of time, treatments pursued, changes noted, changes in exercise routine after the incident.

This field is required.

Date of Surgery (if applicable)

This field is required.

Practice where Surgery was performed (if applicable)

This field is required.

Type of Surgery (if known)

This field is required.

Rehabilitation Questions

Goals for Rehabilitation or Treatment *

This may include short term and long term goals.

This field is required.

How much time do you have for rehabilitation at home *

Be specific with time available and how often per day

5-10 minutes

10-20 minutes

20+ minutes

Once a day

Twice a day

More than twice a day

This field is required.

How did you hear about us?

This field is required.

Veterinary Referral *

Did you get referred to High Five Paws by your Veterinary Clinic?

Yes

This field is required.

Additional Notes or Concerns:

Let us know if there is anything additional we should be aware of.

Do you consent to High Five Paws using photos or videos of the sessions on our website or social media? *

Consent will always be sought prior to publishing any photos or videos for your ease of mind.

Yes

This field is required.

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Please contact your Veterinary Clinic to send a referral at least two days prior to your appointment.

A quick referral ensures that we have the right medical diagnosis and surgical history to create a safe and customized plan for your pet’s needs.

This can easily be done by completing the “Veterinary Referral” Form found on this website and forwarding any history to high5pawsrehab@gmail.com.