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