Follow Up Questionnaire
General Information
Date
-
Month
-
Day
Year
Date
Owner Name
First Name
Last Name
Pet Name
Who would you like us to share your pet's progress with?
Primary Care Veterinarian
Specialty Veterinarian
Primary and Specialty Care Veterinarian
Please list the clinic name for the above selected:
Please list the clinic phone number for the above selected:
Please enter a valid phone number.
Format: (000) 000-0000.
Please list clinic name(s) and phone number(s) for selected veterinarians
Is there anyone else you'd like us to share this information with? Please list name, clinic name, title, and phone number for each:
Concerns and Information
Please fill out the following in as much detail as possible. Your responses are important for the doctor to have a thorough understanding of what is going on with your pet at home.
Has your pet seen your primary care vet or a specialist recently for this or any other condition?
Yes
No
Were any diagnostic tests (x-rays, bloodwork, ultrasound) completed?
Yes
No
Please list the practice contact information for practice visited so we can request records.
How do you feel your pet is doing with therapy thus far?
Better
Worse
No Change
Please describe any of the changes in ability, behavior, or activity that you have observed.
Please note if any particular therapy that seems to help (or not help) more.
Do you have any new goals or concerns?
Yes
No
Please describe.
Does your pet currently have difficulty with, or require assistance for any normal activities (getting up from lying down, walking, stairs/steps, in/out of car, posturing to urinate/ defecate)?
Yes
No
If yes, please describe.
Has this changed?
Yes
No
Please describe what is happening now, vs. what happened before.
Do you see signs of pain or anxiety such as panting, pacing, restlessness, licking/chewing at a specific area, shaking/trembling, limping, whining/crying?
Yes
No
If yes, please describe.
If yes, please describe.
Any signs of weakness such as slipping, scuffing toenails, knuckling, stumbling, difficulty getting up?
Yes
No
If yes, please describe.
If yes, please describe.
Have you noted any new pattern with your pet’s condition (better or worse with certain time of day, weather, specific activity or level of activity)?
Yes
No
If yes, please describe.
If yes, please describe.
Can you describe your pet’s activity in a typical day/ week? Please list frequency and length of walks(distance of time) and note any changes since our last progress check.
Are you currently doing home therapy (massage, passive range of motion, electrical stimulation, exercises) for your pet?
Yes
No
If yes, how do you feel things are going?
Are there any concerns with the at home therapy?
Yes
No
If there are no concerns, would you like to know more things you can do at home?
Yes
No
If no, would you be willing to learn?
Yes
No
Has your pet’s main diet or routinely fed treats changed in type or amount fed?
Yes
No
If yes, please note new brand, formula, amount fed and frequency as well as when the change was made as well as noted response.
Please list all current supplements and medications given regularly or intermittently to your pet. Include brand, formula, strength, dose and frequency as well as any response noted and when started (ok to simply note over 6 months duration vs exact start). Include recently (last 3 months) discontinued products and reason discontinued.
Are there any other products or therapies that you have heard about that you would like to discuss with the doctor?
Yes
No
Please list.
Does your pet have any new allergies or hypersensitivities? Any new adverse reactions to foods, vaccines or medication?
Yes
No
If yes, please describe.
Does your pet have any new health issues or injuries? Any changes to chronic health conditions?
Yes
No
If yes, please describe.
Submit
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