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Canine Functional Questionnaire
Please list your primary veterinarian:
Please list any other veterinarians or care team members that should receive records from today.
What is the reason for today’s visit?
Please list any past surgeries or major medical problems:
What is your primary goal for your pet (ie return to sport, reduce pain, ability to go for walks)?
Do you think your pet is in pain?
Yes
No
If yes, please explain:
What makes your pet’s symptoms better?
What makes your pet’s symptoms worse?
Activity
If your pet is currently on activity restrcition, what was your pet's activity level prior to surgery and /or injury? Please include walks, off-leash playtime, doggie daycare, dog parks, and be as specific as possible.
What is your pet's current activity level? Please include walks, off-leash playtime, doggie daycare, dog parks, and be as specific as possible.
Please list your pet’s favorite activities (walks, chasing ball, chasing laser, playing at the dog park, etc.):
Does your pet participate in canine sports (agility, obedience, flyball, field trials, etc.)?
Yes
No
If yes, please describe (type of sport, training frequency, competition frequency):
Is your pet currently able to participate in the above activities?
Yes
No
If yes, are there any limitations to your pet doing these activities (sore, limping, painful, stiff after)?
Yes
No
If no, what are the main reasons your pet cannot participate in these activities?
Please describe your pet’s home environment (other pets, access to stairs, hardwood floors, etc):
Diet
Please list diet and treats given (include the name/brand, amount given, and how often):
What is your pet’s favorite treat?
Does your pet have any food allergies or sensitivities?
Yes
No
If yes, please describe:
Medication
Please list any oral or topical supplements or herbal remedies that are given (include name/brand, dose, and frequency):
Please list all medications (include the name, dosage, and frequency):
Do we have permission to offer your pet peanut butter?
Yes
No
In the event that your pet needs to be dropped off and spend the day with us for therapy or diagnostics, does your pet tolerate being in a cage or run?
Yes
No
Some of our treatments require direct skin contact. Do we have permission to clip/shave your pet’s fur?
Yes
No
Your Name:
Your Email
Your Signature
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