Pre-Assessment Questionnaire

Fill in this questionnaire to help us gather important information and focus ahead of your visit.

Pre-Assessment Questionnaire

Thank you for putting your much-loved pet’s care in our hands. To enable us to provide the best possible outcome for them, please fill in this questionnaire to help us gather important information and focus ahead of your visit. Please continue overleaf to tell us more!

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Owners Details

Name*

First Last

Email*

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

About my pet

Pet Name

Date of Birth

Breed/Cross of:*

Sex

Favourite things to eat and do:*

Fears/anxieties/things that might make their visit difficult:*

Usual food and mealtimes:*

About my pet’s environment

We live in a:*

My pet is allowed upstairs?*

Can go on furniture?*

The flooring in my house is:*

My pet can go in a private garden:*

Other animal(s) in our home:

Has your pet travelled outside the UK?*

If so, where?

About my pet’s daily routine (before problem)

Get up about:*

Go to bed about:*

Naps?:*

Walks per day?*

On/Off lead?

With me/ another person*

Terrain we walk on:*

Other dog(s) on our walks?*

Free time in the garden?*

Play with ball/frisbee etc?*

About my pet’s allergies/ medical problems

Allergies:*

Vaccinated?

Adverse reactions to anything?*

Previous serious medical problems / hospital stays:*

Previous operations (other than neutering):*

About my pet’s current problem

What you first saw, and when?*

What do they struggle to do normally?*

Does it change as the day goes on, and is there any activity that makes them worse or better?*

Have things changed in response to medication, and if so, how?*

Is the problem getting better or worse at all?*

Please provide video footage of your pet showing their problem if possible.

Max. file size: 256 MB.

Your concerns and desired outcome

Take a moment to tell us your worries and concerns for your pet, and what you hope they will be able to accomplish once they recover:*

Any additional information we may need to know about

Consent

We like to share stories of the work we do at the Animal Rehabilitation Centre (ARC) on our social media account, website & in promotional material. Always on the look out for new material, we should be grateful if you would consider allowing us to share photos, videos and stories about your pet and, if you are happy for us to do so, ask you click the boxes below to provide your consent.

Comments

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Pre-Assessment Questionnaire

Fill in this questionnaire to help us gather important information and focus ahead of your visit.