Owner Questionnaire: Effect of treatment for arthritis or orthopedic related pain

To assess and improve the outcome of your pet’s therapy, Veterinary Specialists of Alaska would appreciate if you could please fill out this questionnaire. Thank you very much for your cooperation!

1.) Orthopedic Questionnaire

Please complete the questionnaire by selecting one option of each activity from each question. (Example: Getting up is a little problematic [score = 1]).

No Problem = 0 | A Little Problem = 1 | Quite A Problem = 2 | A Severe Problem = 3 | Impossible = 4

2.) Current NSAID (check one, include dose, and date when it was started. Does it help? Any side effects?)

3.) Current Supplements (check one, include dose, and date when it was started, did it help?)

4.) Other Medications

(list name, amount, and duration of administration)

5.) Current Diet

(Brand name, how much do you currently give?)

6.) Participation in the Veterinary Specialists of Alaska physical rehabilitation program?

Dermatology History Form

Select all that apply
Check all that apply
Check all that apply
Check all that apply
(explain briefly)
(in percentage %)
(in percentage %)
(Please provide both the brand name and primary protein)
(Please provide both the brand name and primary protein)
(Check any that apply)

Physical Rehabilitation Referral Form

***Please fax or e-mail any pertinent patient records or use the file upload button below to attach them to this form***
Fax: (907) 929-3320
Email: reception.vsoa@ak.net

Case Referral Form

Client

Pet

Referral

If you are unable to attach the results using the file uploader, please fax them to (907) 929-3320 or e-mail them to reception.vsoa@ak.net