[et_pb_section fb_built=”1″ _builder_version=”4.27.0″ _module_preset=”default” custom_margin_tablet=”70px||||false|false” custom_margin_phone=”100px||||false|false” custom_margin_last_edited=”on|tablet” global_colors_info=”{}”][et_pb_row _builder_version=”4.27.0″ _module_preset=”default” custom_padding=”10px||10px||true|true” border_radii=”on|7px|7px|7px|7px” border_color_all=”#E02B20″ global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][et_pb_text _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”]<\/p>\n
[\/et_pb_text][et_pb_text _builder_version=”4.27.0″ _module_preset=”default” custom_margin=”||50px||false|false” global_colors_info=”{}”]Please complete this form prior to an Initial Physiotherapy Consultation.[\/et_pb_text][et_pb_contact_form use_spam_service=”on” recaptcha_list=”JAWS 4049|JAWS 4049-0″ recaptcha_min_score=”0.3″ email=”questionnaire@joseesanimalwellness.com” custom_message=”Subject: Questionnaire %%pet-name%%||et_pb_line_break_holder||Owner’s Full Name: %%owners-name%%||et_pb_line_break_holder||||et_pb_line_break_holder||Pet’s Name: %%pet-name%%||et_pb_line_break_holder||||et_pb_line_break_holder||Species\/Breed: %%species-breed%%||et_pb_line_break_holder||||et_pb_line_break_holder||Pet’s Age: %%pets-age%%||et_pb_line_break_holder||||et_pb_line_break_holder||Pet’s Current Body Weight: %%pets-bodyweight%%||et_pb_line_break_holder||||et_pb_line_break_holder||Sex: %%sex%%||et_pb_line_break_holder||||et_pb_line_break_holder||Spayed\/Neutered: %%spayed%%||et_pb_line_break_holder||||et_pb_line_break_holder||Can your pet position themselves to urinate?: %%position-urinate%%||et_pb_line_break_holder||||et_pb_line_break_holder||Can your pet position themselves to defacate?: %%position-defacate%%||et_pb_line_break_holder||||et_pb_line_break_holder||Can your pet go from lying to sitting and vice versa?: %%lying-to-sitting%%||et_pb_line_break_holder||||et_pb_line_break_holder||Can your pet go from sitting to standing and vice versa?: %%sitting-to-standing%%||et_pb_line_break_holder||||et_pb_line_break_holder||Can your pet go from lying to standing and vice versa?: %%lying-to-standing%%||et_pb_line_break_holder||||et_pb_line_break_holder||Can your pet roll over?: %%can-roll-over%%||et_pb_line_break_holder||||et_pb_line_break_holder||Can your pet scratch behind its ears?: %%can-pet-scratch-ears%%||et_pb_line_break_holder||||et_pb_line_break_holder||Can your pet ascend stairs?: %%can-ascend-stairs%%||et_pb_line_break_holder||||et_pb_line_break_holder||Can your pet descend stairs?: %%can-descent-stairs%%||et_pb_line_break_holder||||et_pb_line_break_holder||Is your pet able to walk up an incline\/hill?: %%incline%%||et_pb_line_break_holder||||et_pb_line_break_holder||Is your pet able to get in\/out of the car?: %%car%%||et_pb_line_break_holder||||et_pb_line_break_holder||Is your pet able to get on\/off the couch or bed?: %%bed%%||et_pb_line_break_holder||||et_pb_line_break_holder||Is your pet able to run?: %%run%%||et_pb_line_break_holder||||et_pb_line_break_holder||Is your pet able to jump?: %%jump%%||et_pb_line_break_holder||||et_pb_line_break_holder||Has your pet experienced an increase or decrease in weight?: %%weight%%||et_pb_line_break_holder||||et_pb_line_break_holder||Has your pet experienced an increase or decrease in endurance?: %%endurance%%||et_pb_line_break_holder||||et_pb_line_break_holder||Has your pet experienced an increase or decrease in temperament\/attitude?: %%temprament%%||et_pb_line_break_holder||||et_pb_line_break_holder||Temperament\/attitude elaboration: %%temerament-elaboration%%||et_pb_line_break_holder||||et_pb_line_break_holder||What does your pet like to do for fun?: %%for-fun%%||et_pb_line_break_holder||||et_pb_line_break_holder||Are they able to do that activity?: %%able-to-do-fun-activity%%||et_pb_line_break_holder||||et_pb_line_break_holder||Fun activity elaboration: %%fun-activity-elaboration%%||et_pb_line_break_holder||||et_pb_line_break_holder||Has your pet been able to resume normal activities?: %%normal-activity%%||et_pb_line_break_holder||||et_pb_line_break_holder||Normal activity elaboration: %%normal-activity-elaboration%%||et_pb_line_break_holder||||et_pb_line_break_holder||Is your pet able to go on a walk?: %%able-to-walk%%||et_pb_line_break_holder||||et_pb_line_break_holder||How long (in minutes) are your pet’s walks?: %%able-to-walk-time%%||et_pb_line_break_holder||||et_pb_line_break_holder||Could your pet walk longer?: %%able-to-walk-longer%%||et_pb_line_break_holder||||et_pb_line_break_holder||Does anything prevent him\/her from taking longer walks?: %%able-to-walk-longer-prevention%%||et_pb_line_break_holder||||et_pb_line_break_holder||Longer walk elaboration: %%longer-walk-elaboration%%||et_pb_line_break_holder||||et_pb_line_break_holder||Do you notice any problems are worse after taking a walk?: %%problems-after-walking%%||et_pb_line_break_holder||||et_pb_line_break_holder||Problems after walking elaboration: %%problems-after-walk-elaboration%%||et_pb_line_break_holder||||et_pb_line_break_holder||Does your pet tire quickly, have to make rest stops, or lag behind during walks?: %%lag-behind%%||et_pb_line_break_holder||||et_pb_line_break_holder||Tired\/Lagging behind elaboration: %%lag-behind-elaboration%%||et_pb_line_break_holder||||et_pb_line_break_holder||Does your pet seem to be in pain?: %%seem-in-pain%%||et_pb_line_break_holder||||et_pb_line_break_holder||In pain elaboration: %%seem-in-pain-elaboration%%||et_pb_line_break_holder||||et_pb_line_break_holder||Is there anything your pet CAN do that they COULD NOT do before?: %%improvement%%||et_pb_line_break_holder||||et_pb_line_break_holder||Improvement elaboration: %%improvement-elaboration%%||et_pb_line_break_holder||||et_pb_line_break_holder||Lameness scale – Standing: %%lameness-standing%%||et_pb_line_break_holder||||et_pb_line_break_holder||Lameness scale – Walking: %%lameness-walking%%||et_pb_line_break_holder||||et_pb_line_break_holder||Lameness scale – Trotting: %%lameness-trotting%%||et_pb_line_break_holder||||et_pb_line_break_holder||Are there any other problems that you have noticed that have no been covered in this form?: %%non-mentionned-problems%%||et_pb_line_break_holder||||et_pb_line_break_holder||Any additional comments?: %%additional-comments%%||et_pb_line_break_holder||” success_message=”Your message has been sent successfully!” submit_button_text=”Send” _builder_version=”4.27.4″ _module_preset=”default” _unique_id=”c9110bcc-6c8a-4e35-8d90-81bc4a0feb32″ form_field_background_color=”#FFFFFF” custom_button=”on” button_text_size=”18px” button_text_color=”#FFFFFF” button_bg_color=”gcid-b77800f7-981e-4e7c-b867-0a0e549b961c” button_border_color=”gcid-b77800f7-981e-4e7c-b867-0a0e549b961c” button_border_radius=”8px” button_use_icon=”off” hover_enabled=”0″ border_radii=”on|5px|5px|5px|5px” border_width_all=”2px” border_color_all=”gcid-b77800f7-981e-4e7c-b867-0a0e549b961c” global_colors_info=”{%22gcid-b77800f7-981e-4e7c-b867-0a0e549b961c%22:%91%22button_bg_color%22,%22button_border_color%22,%22border_color_all%22%93}” sticky_enabled=”0″][et_pb_contact_field field_id=”owners-name” field_title=”Owner’s Full Name” fullwidth_field=”on” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”pet-name” field_title=”Pet’s Name” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”species-breed” field_title=”Species\/Breed” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”pets-age” field_title=”Pet’s Age” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”pets-bodyweight” field_title=”Pet’s Current Body Weight” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”sex” field_title=”Sex” field_type=”radio” radio_options=”%91{%22value%22:%22Male%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Female%22,%22checked%22:0,%22dragID%22:0}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”spayed” field_title=”Spayed\/Neutered” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”position-urinate” field_title=”Can your pet position themselves to urinate?” field_type=”select” select_options=”%91{%22value%22:%221. Not able to perform this activity%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%222. Moderate assistance to perform this activity%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%223. Minimal assistance to perform this activity%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%224. Independent with activity%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%225. N\/A%22,%22checked%22:0,%22dragID%22:3}%93″ fullwidth_field=”on” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”position-defacate” field_title=”Can your pet position themselves to defacate?” field_type=”select” select_options=”%91{%22value%22:%221. Not able to perform this activity%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%222. Moderate assistance to perform this activity%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%223. Minimal assistance to perform this activity%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%224. Independent with activity%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%225. N\/A%22,%22checked%22:0,%22dragID%22:3}%93″ fullwidth_field=”on” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”lying-to-sitting” field_title=”Can your pet go from lying to sitting and vice versa?” field_type=”select” select_options=”%91{%22value%22:%221. Not able to perform this activity%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%222. Moderate assistance to perform this activity%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%223. Minimal assistance to perform this activity%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%224. Independent with activity%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%225. N\/A%22,%22checked%22:0,%22dragID%22:3}%93″ fullwidth_field=”on” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”sitting-to-standing” field_title=”Can your pet go from sitting to standing and vice versa?” field_type=”select” select_options=”%91{%22value%22:%221. Not able to perform this activity%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%222. Moderate assistance to perform this activity%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%223. Minimal assistance to perform this activity%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%224. Independent with activity%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%225. N\/A%22,%22checked%22:0,%22dragID%22:3}%93″ fullwidth_field=”on” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”lying-to-standing” field_title=”Can your pet go from lying to standing and vice versa?” field_type=”select” select_options=”%91{%22value%22:%221. Not able to perform this activity%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%222. Moderate assistance to perform this activity%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%223. Minimal assistance to perform this activity%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%224. Independent with activity%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%225. N\/A%22,%22checked%22:0,%22dragID%22:3}%93″ fullwidth_field=”on” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”can-roll-over” field_title=”Can your pet roll over?” field_type=”select” select_options=”%91{%22value%22:%221. Not able to perform this activity%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%222. Moderate assistance to perform this activity%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%223. Minimal assistance to perform this activity%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%224. Independent with activity%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%225. N\/A%22,%22checked%22:0,%22dragID%22:3}%93″ fullwidth_field=”on” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”can-pet-scratch-ears” field_title=”Can your pet scratch behind its ears?” field_type=”select” select_options=”%91{%22value%22:%221. Not able to perform this activity%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%222. Moderate assistance to perform this activity%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%223. Minimal assistance to perform this activity%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%224. Independent with activity%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%225. N\/A%22,%22checked%22:0,%22dragID%22:3}%93″ fullwidth_field=”on” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”can-ascend-stairs” field_title=”Can your pet ascend stairs?” field_type=”select” select_options=”%91{%22value%22:%221. Not able to perform this activity%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%222. Moderate assistance to perform this activity%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%223. Minimal assistance to perform this activity%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%224. Independent with activity%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%225. N\/A%22,%22checked%22:0,%22dragID%22:3}%93″ fullwidth_field=”on” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”can-descend-stairs” field_title=”Can your pet descend stairs?” field_type=”select” select_options=”%91{%22value%22:%221. Not able to perform this activity%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%222. Moderate assistance to perform this activity%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%223. Minimal assistance to perform this activity%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%224. Independent with activity%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%225. N\/A%22,%22checked%22:0,%22dragID%22:3}%93″ fullwidth_field=”on” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”incline” field_title=”Is your pet able to walk up an incline\/hill?” field_type=”select” select_options=”%91{%22value%22:%221. Not able to perform this activity%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%222. Moderate assistance to perform this activity%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%223. Minimal assistance to perform this activity%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%224. Independent with activity%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%225. N\/A%22,%22checked%22:0,%22dragID%22:3}%93″ fullwidth_field=”on” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”car” field_title=”Is your pet able to get in\/out of the car?” field_type=”select” select_options=”%91{%22value%22:%221. Not able to perform this activity%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%222. Moderate assistance to perform this activity%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%223. Minimal assistance to perform this activity%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%224. Independent with activity%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%225. N\/A%22,%22checked%22:0,%22dragID%22:3}%93″ fullwidth_field=”on” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”bed” field_title=”Is your pet able to get on\/off the couch or bed?” field_type=”select” select_options=”%91{%22value%22:%221. Not able to perform this activity%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%222. Moderate assistance to perform this activity%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%223. Minimal assistance to perform this activity%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%224. Independent with activity%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%225. N\/A%22,%22checked%22:0,%22dragID%22:3}%93″ fullwidth_field=”on” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”run” field_title=”Is your pet able to run?” field_type=”select” select_options=”%91{%22value%22:%221. Not able to perform this activity%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%222. Moderate assistance to perform this activity%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%223. Minimal assistance to perform this activity%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%224. Independent with activity%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%225. N\/A%22,%22checked%22:0,%22dragID%22:3}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”jump” field_title=”Is your pet able to jump?” field_type=”select” select_options=”%91{%22value%22:%221. Not able to perform this activity%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%222. Moderate assistance to perform this activity%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%223. Minimal assistance to perform this activity%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%224. Independent with activity%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%225. N\/A%22,%22checked%22:0,%22dragID%22:3}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”weight” field_title=”Has your pet experienced an increase or decrease in weight?” field_type=”radio” radio_options=”%91{%22value%22:%22Increase%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Decrease%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Same%22,%22checked%22:0,%22dragID%22:1}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”endurance” field_title=”Has your pet experienced an increase or decrease in endurance?” field_type=”radio” radio_options=”%91{%22value%22:%22Increase%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Decrease%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Same%22,%22checked%22:0,%22dragID%22:1}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”temprament” field_title=”Has your pet experienced an increase or decrease in temperament\/attitude?” field_type=”radio” radio_options=”%91{%22value%22:%22Increase%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Decrease%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Same%22,%22checked%22:0,%22dragID%22:1}%93″ fullwidth_field=”on” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”temperament-elaboration” field_title=”Please elaborate” field_type=”text” fullwidth_field=”on” conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22temprament%22,%22condition%22:%22is%22,%22value%22:%22Increase%22},{%22field%22:%22temprament%22,%22condition%22:%22is%22,%22value%22:%22Decrease%22}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”for-fun” field_title=”What does your pet like to do for fun?” fullwidth_field=”on” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”able-to-do-fun-activity” field_title=”Are they able to do that activity” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Sometimes%22,%22checked%22:0,%22dragID%22:1}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”fun-activity-elaboration” field_title=”Please elaborate” field_type=”text” fullwidth_field=”on” conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22able-to-do-fun-activity%22,%22condition%22:%22is%22,%22value%22:%22No%22},{%22field%22:%22able-to-do-fun-activity%22,%22condition%22:%22is%22,%22value%22:%22Sometimes%22}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”normal-activity” field_title=”Has your pet been able to resume normal activities?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Sometimes%22,%22checked%22:0,%22dragID%22:1}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”normal-activity-elaboration” field_title=”Please elaborate” field_type=”text” fullwidth_field=”on” conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22normal-activity%22,%22condition%22:%22is%22,%22value%22:%22No%22},{%22field%22:%22normal-activity%22,%22condition%22:%22is%22,%22value%22:%22Sometimes%22}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”able-to-walk” field_title=”Is your pet able to go on a walk?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Sometimes%22,%22checked%22:0,%22dragID%22:1}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”able-to-walk-time” field_title=”How long (in minutes) are your pet’s walks?” fullwidth_field=”on” conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22able-to-walk%22,%22condition%22:%22is%22,%22value%22:%22Yes%22},{%22field%22:%22able-to-walk%22,%22condition%22:%22is%22,%22value%22:%22Sometimes%22}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”able-to-walk-longer” field_title=”Could your pet walk longer?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Sometimes%22,%22checked%22:0,%22dragID%22:1}%93″ fullwidth_field=”on” conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22able-to-walk%22,%22condition%22:%22is%22,%22value%22:%22Yes%22},{%22field%22:%22able-to-walk%22,%22condition%22:%22is%22,%22value%22:%22Sometimes%22}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”able-to-walk-longer-prevention” field_title=”Does anything prevent him\/her from taking longer walks?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Sometimes%22,%22checked%22:0,%22dragID%22:1}%93″ fullwidth_field=”on” conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22able-to-walk%22,%22condition%22:%22is%22,%22value%22:%22Yes%22},{%22field%22:%22able-to-walk%22,%22condition%22:%22is%22,%22value%22:%22Sometimes%22}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”longer-walk-elaboration” field_title=”Please elaborate” field_type=”text” fullwidth_field=”on” conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22problems-after-walking%22,%22condition%22:%22is%22,%22value%22:%22Yes%22},{%22field%22:%22problems-after-walking%22,%22condition%22:%22is%22,%22value%22:%22Sometimes%22}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”problems-after-walking” field_title=”Do you notice any problems (limping, stiffness, etc.) are worse after taking a walk?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Sometimes%22,%22checked%22:0,%22dragID%22:1}%93″ fullwidth_field=”on” conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22can-walk%22,%22condition%22:%22is%22,%22value%22:%22Yes%22},{%22field%22:%22can-walk%22,%22condition%22:%22is%22,%22value%22:%22Sometimes%22}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”problems-after-walk-elaboration” field_title=”Please elaborate” field_type=”text” fullwidth_field=”on” conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22can-walk%22,%22condition%22:%22is%22,%22value%22:%22Yes%22},{%22field%22:%22can-walk%22,%22condition%22:%22is%22,%22value%22:%22Sometimes%22}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”lag-behind” field_title=”Does your pet tire quickly, have to make rest stops, or lag behind during walks?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Sometimes%22,%22checked%22:0,%22dragID%22:1}%93″ fullwidth_field=”on” conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22able-to-walk%22,%22condition%22:%22is%22,%22value%22:%22Yes%22},{%22field%22:%22able-to-walk%22,%22condition%22:%22is%22,%22value%22:%22Sometimes%22}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”lag-behind-elaboration” field_title=”Please elaborate” field_type=”text” fullwidth_field=”on” conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22lag-behind%22,%22condition%22:%22is%22,%22value%22:%22Yes%22},{%22field%22:%22lag-behind%22,%22condition%22:%22is%22,%22value%22:%22Sometimes%22}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”seem-in-pain” field_title=”Does your pet seem to be in pain?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Sometimes%22,%22checked%22:0,%22dragID%22:1}%93″ fullwidth_field=”on” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”seem-in-pain-elaboration” field_title=”Please elaborate” field_type=”text” fullwidth_field=”on” conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22seem-in-pain%22,%22condition%22:%22is%22,%22value%22:%22Yes%22},{%22field%22:%22seem-in-pain%22,%22condition%22:%22is%22,%22value%22:%22Sometimes%22}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”improvement” field_title=”Is there anything your pet CAN do now that they COULD NOT do before?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Sometimes%22,%22checked%22:0,%22dragID%22:1}%93″ fullwidth_field=”on” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”improvement-elaboration” field_title=”Please elaborate” field_type=”text” fullwidth_field=”on” conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22improvement%22,%22condition%22:%22is%22,%22value%22:%22Yes%22},{%22field%22:%22improvement%22,%22condition%22:%22is%22,%22value%22:%22Sometimes%22}%93″ _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”lameness-standing” field_title=”Lameness Scale – Standing” field_type=”radio” radio_options=”%91{%22value%22:%220 – Normal Stance%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%221 – Slightly abnormal stance (partial weight-bearing)%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%222 – Moderately abnormal stance (toe-touch weight-bearing)%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%223 – Severly abnormal stance (holds limb off floor)%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%224 – Unable to stand%22,%22checked%22:0,%22dragID%22:3}%93″ _builder_version=”4.27.2″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”lameness-walking” field_title=”Lameness Scale – Walking” field_type=”radio” radio_options=”%91{%22value%22:%220 – No Lameness%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%221 – Lameness barely perceptible%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%222 – Lameness obvious, but not severe%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%223 – Severe lameness%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%224 – Partial or complete non-weight-bearing lameness%22,%22checked%22:0,%22dragID%22:3}%93″ _builder_version=”4.27.2″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”lameness-trotting” field_title=”Lameness Scale – Trotting” field_type=”radio” radio_options=”%91{%22value%22:%220 – No Lameness%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%221 – Lameness barely perceptible%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%222 – Lameness obvious, but not severe%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%223 – Severe lameness%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%224 – Partial or complete non-weight-bearing lameness%22,%22checked%22:0,%22dragID%22:3}%93″ fullwidth_field=”on” _builder_version=”4.27.2″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”non-mentionned-problems” field_title=”Are there any other problems that you have noticed that have not been covered in this form?” field_type=”text” required_mark=”off” fullwidth_field=”on” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”additional-comments” field_title=”Any additional comments?” field_type=”text” required_mark=”off” fullwidth_field=”on” _builder_version=”4.27.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][\/et_pb_contact_form][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"
Functional QuestionnairePlease complete this form prior to an Initial Physiotherapy Consultation.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"nf_dc_page":"","_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","om_disable_all_campaigns":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-111","page","type-page","status-publish","hentry"],"yoast_head":"\n