Rehab Pet Pre-Registration - CVETS - Columbia Veterinary Emergency Trauma and Specialty

Owner Name*

First Last

Pet Name*

Email*

Primary Phone*

Backup Phone

Preferred Method of Contact*

Call
Text
Email

What makes the issue better after an acute episode of worsening?*

Additional Concerns

When are these issues most noticeable?*

What makes the issue better after an acute episode of worsening?*

Giving their medications
Resting more
Changing sleeping locations

Anything else that makes the issue better after an acute episode of worsening?

What activities make the issue worsen?*

What kind of physical assistance are they currently requiring?*

What are the tasks they must complete daily? Example: completing a several-mile walk/run with owner, playing fetch, climbing stairs, playing with toddlers, etc*

Do they currently have exercises they do at home? Examples: walking or running with the family, playing fetch, other working jobs.*

What texture of flooring is in the house?*

Carpet
Wood
Vinyl
Rugs

Any additional floor textures in the house?

What type of flooring do they prefer? Example: purposely walk on rugs or always sleeps on the wooden floor*

Are there stairs in the house or on the porch? If so, how do they do on them?*

What kind of accessories do they wear at home?*

What kind of housemates do they have?*

How much pain do you think your pet is in on a scale of 0 to 10 (0 being completely comfortable, 10 being unwilling to move/eat)*

How much pain do you think your pet is in today specifically (0 being completely comfortable, 10 being unwilling to move/eat)?*

The following questions are to be answered with information from the past 7-10 days. These functional assessments assist in determining pain levels by using the amount of interference it has had on their daily activities.

General Activity*

0 - no interference, did all their normal things happily and energetically
5 - decreased activity, doesn’t want to play or do their normal things
10 - dull, lying around with no interest in doing things they normally like

Enjoyment of life*

0 - no interference, did all their normal things happily and energetically
5 - decreased activity, doesn’t want to play or do their normal things
10 - dull, lying around with no interest in doing things they normally like

Ability to rise from lying down to standing*

0 - no interference, popped right up
5 - it took them a couple seconds or they got up strategically to avoid putting weight on an area
10 - they needed assistance, or would not get up, or cried in pain

Ability to walk*

0 - walks smoothly with no issue
5 - moves slower or does not use all their legs
10 - unwilling to walk far before laying down again

Ability to run*

0 - runs smoothly with no issue
5 - not using all legs or moving slower
10 - unwilling to run or cries in pain

Ability to climb stairs*

0 - walks up them with no problem
5 - climbs slowly or not using all legs
10 - unwilling to do steps

What type of food are you feeding?*

Dry
Wet
Semi-Wet

How often do you feed your pet?*

Once per day
Twice per day
Three times per day

Do they have food allergies or intolerances?*

Do they get human food/ table scraps?*

What kind of supplements are being given and how often?*

What medications are currently being given? How many milligrams? How often? (Please include flea/tick/heartworm medications.)*

Have they had any past surgeries or visits to the emergency room?*

Do they have any diseases, illnesses, or conditions that compromise their immune system?*

Do they have any of medical conditions?*

Any other medical conditions that we should know about?

For any commands that are not exactly as written please type out what your command is and what they are to do when you use it. If you use hand signals, please include them (Ex. come, sit, lay)

Do they know any tricks? Please include the command and the action.

Any particular things they do not appreciate? Examples include touching their feet, ears, or mouth.

What current issue will we be addressing during the rehabilitation therapy appointments?

What improvements would you like to see in your pet’s condition through these appointments?

What can we in the rehabilitation department do to improve your relationship with your pet?

We will do our best to make scheduling as convenient as possible for you and your pet. More details on scheduling will be discussed during appointments! This section is just to get an idea of your and your pet’s general needs.

How frequently is it feasible for your pet to get to CVETS for an appointment?*

Once a week
Twice a week
Three times a week

What days work best for appointments?*

What time is the most ideal for appointments?*

8am - 12pm
After 12pm
After 3pm

Payment Policy & Treatment Consent*

I agree to the privacy policy and treatment consent.

I understand and agree to authorize treatment. All accounts must be paid at time of discharge. I am 18 years old or older and am accepting financial responsibility for this patient’s medical care and assume responsibility for all fees associated with the collection of any unpaid balance.

Photo, Video, and/or Recording Consent*

CVETS or its officers, employees, or agents may take photos of patients for education, advertising, media, video, audio or other marketing purposes.

I DO authorize photos, video, or recordings of my pet.
I do NOT authorize photos, video, or recordings of my pet.

Comments

This field is for validation purposes and should be left unchanged.

REHAB REGISTRATION

Get Set Up For Care.

THINK AHEAD

The following questions are to be answered with information from the past 7-10 days. These functional assessments assist in determining pain levels by using the amount of interference it has had on their daily activities.

We will do our best to make scheduling as convenient as possible for you and your pet. More details on scheduling will be discussed during appointments! This section is just to get an idea of your and your pet’s general needs.