Functional Questionnaire Please complete this form prior to an Initial Physiotherapy Consultation. Owner's Full Name Pet's Name Species/Breed Pet's Age Pet's Current Body Weight Sex Sex Male Female Spayed/Neutered Spayed/Neutered Yes No Can your pet position themselves to urinate? Can your pet position themselves to urinate?1. Not able to perform this activity2. Moderate assistance to perform this activity3. Minimal assistance to perform this activity4. Independent with activity5. N/A Can your pet position themselves to defacate? Can your pet position themselves to defacate?1. Not able to perform this activity2. Moderate assistance to perform this activity3. Minimal assistance to perform this activity4. Independent with activity5. N/A Can your pet go from lying to sitting and vice versa? Can your pet go from lying to sitting and vice versa?1. Not able to perform this activity2. Moderate assistance to perform this activity3. Minimal assistance to perform this activity4. Independent with activity5. N/A Can your pet go from sitting to standing and vice versa? Can your pet go from sitting to standing and vice versa?1. Not able to perform this activity2. Moderate assistance to perform this activity3. Minimal assistance to perform this activity4. Independent with activity5. N/A Can your pet go from lying to standing and vice versa? Can your pet go from lying to standing and vice versa?1. Not able to perform this activity2. Moderate assistance to perform this activity3. Minimal assistance to perform this activity4. Independent with activity5. N/A Can your pet roll over? Can your pet roll over?1. Not able to perform this activity2. Moderate assistance to perform this activity3. Minimal assistance to perform this activity4. Independent with activity5. N/A Can your pet scratch behind its ears? Can your pet scratch behind its ears?1. Not able to perform this activity2. Moderate assistance to perform this activity3. Minimal assistance to perform this activity4. Independent with activity5. N/A Can your pet ascend stairs? Can your pet ascend stairs?1. Not able to perform this activity2. Moderate assistance to perform this activity3. Minimal assistance to perform this activity4. Independent with activity5. N/A Can your pet descend stairs? Can your pet descend stairs?1. Not able to perform this activity2. Moderate assistance to perform this activity3. Minimal assistance to perform this activity4. Independent with activity5. N/A Is your pet able to walk up an incline/hill? Is your pet able to walk up an incline/hill?1. Not able to perform this activity2. Moderate assistance to perform this activity3. Minimal assistance to perform this activity4. Independent with activity5. N/A Is your pet able to get in/out of the car? Is your pet able to get in/out of the car?1. Not able to perform this activity2. Moderate assistance to perform this activity3. Minimal assistance to perform this activity4. Independent with activity5. N/A Is your pet able to get on/off the couch or bed? Is your pet able to get on/off the couch or bed?1. Not able to perform this activity2. Moderate assistance to perform this activity3. Minimal assistance to perform this activity4. Independent with activity5. N/A Is your pet able to run? Is your pet able to run?1. Not able to perform this activity2. Moderate assistance to perform this activity3. Minimal assistance to perform this activity4. Independent with activity5. N/A Is your pet able to jump? Is your pet able to jump?1. Not able to perform this activity2. Moderate assistance to perform this activity3. Minimal assistance to perform this activity4. Independent with activity5. N/A Has your pet experienced an increase or decrease in weight? Has your pet experienced an increase or decrease in weight? Increase Decrease Same Has your pet experienced an increase or decrease in endurance? Has your pet experienced an increase or decrease in endurance? Increase Decrease Same Has your pet experienced an increase or decrease in temperament/attitude? Has your pet experienced an increase or decrease in temperament/attitude? Increase Decrease Same Please elaborate What does your pet like to do for fun? Are they able to do that activity Are they able to do that activity Yes No Sometimes Please elaborate Has your pet been able to resume normal activities? Has your pet been able to resume normal activities? Yes No Sometimes Please elaborate Is your pet able to go on a walk? Is your pet able to go on a walk? Yes No Sometimes How long (in minutes) are your pet's walks? Could your pet walk longer? Could your pet walk longer? Yes No Sometimes Does anything prevent him/her from taking longer walks? Does anything prevent him/her from taking longer walks? Yes No Sometimes Please elaborate Do you notice any problems (limping, stiffness, etc.) are worse after taking a walk? Do you notice any problems (limping, stiffness, etc.) are worse after taking a walk? Yes No Sometimes Please elaborate Does your pet tire quickly, have to make rest stops, or lag behind during walks? Does your pet tire quickly, have to make rest stops, or lag behind during walks? Yes No Sometimes Please elaborate Does your pet seem to be in pain? Does your pet seem to be in pain? Yes No Sometimes Please elaborate Is there anything your pet CAN do now that they COULD NOT do before? Is there anything your pet CAN do now that they COULD NOT do before? Yes No Sometimes Please elaborate Lameness Scale - Standing Lameness Scale - Standing 0 - Normal Stance 1 - Slightly abnormal stance (partial weight-bearing) 2 - Moderately abnormal stance (toe-touch weight-bearing) 3 - Severly abnormal stance (holds limb off floor) 4 - Unable to stand Lameness Scale - Walking Lameness Scale - Walking 0 - No Lameness 1 - Lameness barely perceptible 2 - Lameness obvious, but not severe 3 - Severe lameness 4 - Partial or complete non-weight-bearing lameness Lameness Scale - Trotting Lameness Scale - Trotting 0 - No Lameness 1 - Lameness barely perceptible 2 - Lameness obvious, but not severe 3 - Severe lameness 4 - Partial or complete non-weight-bearing lameness Are there any other problems that you have noticed that have not been covered in this form? Any additional comments? 3 + 8 = Send
