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609.259.8300
315 Robbinsville-Allentown Rd., Robbinsville, NJ 08691
2834 Route 73N, Maple Shade, NJ 08052
507 Route 70, Brick, NJ 08723

Rehabilitation Questionnaire








Excellent   Very Good   Good   Fair   Poor


No   Yes


Is completely uninterested in its surroundings, sleeps all the time
Will show interest, but no longer comes to greet you
Is mostly interested in life and food, but reluctant to play
Plays only when encouraged, and not for long
Has had no change in personality


Seeks more affection than usual
Has difficulty getting up from a lying position
Lies very still
Reluctant to move
Shows trembling
Becomes restless
Repetitively gets up and lies down
Shows circling
Does not wag tail
Trouble posturing for bowel movements
Other


No   Yes


Cannot manage any steps without assistance
Cannot jump onto the furniture without assistance
Cannot manage a full flight of steps (only 2 to 4 steps alone)
Cannot get into the vehicle without assistance
Manages a full flight of steps, but has difficulty
Has no trouble jumping
Can only go upstairs without assistance
Has trouble on slippery floors
Can only go downstairs without assistance
No problems on stairs


Protects hurt body part
Hides
Doesn't put weight on a limb
Limps
Doesn't want to be held or picked up
Does not like to be brushed/groomed
Other


Less than 5 minutes
More than 30 minutes/my pet doesn't get tire or sore
10 to 20 minutes
Does not show signs until finished walking and rests for a while (ie: will stiffen up)


Slowly, over the course of a few months   Suddenly, within days or a few weeks


Within the past few days   Within the past few weeks    Not applicable


Yes   No   There is no morning stiffness


Yes   No   Unsure


Physical activity/exercise
Nutritional supplements
Weight management
Physical rehabilitation/chiropractic/massage
Cold or heat treatment
Medication
Laser
None
Other


Prescription medication from veterinarian

Over-the-counter medication

Aspirin

Glucosamine human medication (brand)

Veterinary joint supplement (brand)

Herbal supplement (brand)

Other

None


Kidney disease
Skin disease
Liver disease
Active infection
Lung disease
Bladder problems
Cardiovascular disease
Other