Please complete the form below and submit

Downloadable form for faxing or uploading

Rehab Functional Questionnaire

Online Submission

Client (required)

Patient (required)

Medications (required)

(name, dosage and frequency give)

Surgical Procedures & Dates (required)

Pre-existing Conditions (required)

Allergies (required)



Please complete the questions on this form pertaining to your pet's functional ability to help us monitor its' progress.

1. = not able to perform this activity (needs assistance 100% of the time)
2. = moderate assistance to perform activity (needs assistance more than 50% of the time)
3. = minimal assistance to perform activity (needs assistance less than 50% of the time)
4. = independent with activity (no assistance needed)
5. = N/A



Able to maintain a standing position? (required)
 1 2 3 4 5

Able to position itself to urinate? (required)
 1 2 3 4 5

Able to position itself to defecate? (required)
 1 2 3 4 5

Able to transfer from lying to sitting and vise versa? (required)
 1 2 3 4 5

Able to transfer from sitting to standing and vise versa? (required)
 1 2 3 4 5

Able to transfer from lying to standing and vise versa? (required)
 1 2 3 4 5

Able to roll over? (required)
 1 2 3 4 5

Able to scratch behind its ears? (required)
 1 2 3 4 5

Able to ascend stairs? (required)
 1 2 3 4 5

Able to descend stairs? (required)
 1 2 3 4 5

Able to walk up an incline/hill? (required)
 1 2 3 4 5

Able to get in and out of a car? (required)
 1 2 3 4 5

Able to get on and off a couch or bed? (required)
 1 2 3 4 5

Able to run? (required)
 1 2 3 4 5

Able to jump? (required)
 1 2 3 4 5


Please answer the following by selecting the corresponding answer for the past 6 months.



Experienced a change in weight (required)
 Increase Decrease Same

Experienced a change in endurance (required)
 Increase Decrease Same

Experienced a change in level of play (required)
 Increase Decrease Same

Have you noticed a change in your pets temperament/attitude? (required)
 Yes No

What does your pet like to do for fun? (required)

Is she or he able to do these activities? (required)
 Yes No

Does your pet like to go for walks? (required)
 Yes No

Are there any other problems or concerns that you have noticed that have not been covered in this form?

Are there any other injuries or illnesses known, other then the reason for the rehab referral?

Goals and expectations of rehab for your pet

Additional Comments