Functional Questionnaire

Save time during your next appointment! Complete your required questionnaire form online to help us prepare for your pet’s care.

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Important Information Before Your Visit

Please complete this form as thoroughly and accurately as possible to help us get to know you and your pet(s) before your scheduled appointment with Dr. Koh.

Kindly note that this form should only be filled out after your pet’s appointment has been confirmed.

We do not provide urgent care or emergency services. If your pet is experiencing an emergency or requires immediate attention, please contact your local veterinary hospital for assistance. Your pet’s safety and well-being are our top priority.

Patient Information

Owner Name *

First

Last

Phone Number *

Email *

Pet Name *

Sex *

Male
Neutered Male
Female
Spayed Female

Breed *

Age *

Weight *

Primary Veterinarian/Clinic

Primary Concern

What problem(s) are you bringing your pet in for today?

When and how did the issue(s) begin?

Has the condition changed over time? If so, how?

Does your pet appear to be in pain now? From 0-10, how would you rate their pain level today?

What diagnostics (X-rays, bloodwork, MRI, etc.) have been performed by your veterinarian for this condition?

What treatments (medical or surgical) has your pet received? Please list dates, procedures, and whether they were effective.

Have you tried any therapies (rehabilitation, laser, acupuncture, etc.)? If yes, did they help

List any past or current medical issues (including chronic conditions, surgeries, allergies, or injuries). This may impact treatment and rehabilitation options.

List all current medications, supplements, and herbals (prescription & over-the-counter), along with their doses and frequency.

Diet & Lifestyle

Describe your pet’s diet (brand, full name, amount per day)

How long are your pet’s daily walks?

How many times per day?

Is your pet dog-reactive?

Constitution & Personality Traits (Choose the one that best represents your pet)

Wood – Adventurous, fearless, dominant, bossy, competitive, impatient, easily irritated, quick to anger.
Fire – High energy, easily excited, extroverted, loves attention, difficult to calm down.
Earth – Easygoing, mellow, stoic, tolerant, nurturing, enjoys caring for others.
Metal – Aloof, dignified, confident, organized, excellent self-control, prefers routine.
Water – Timid, cautious, nervous around new people/sounds/places, may hide or become defensive.

Mobility & Function Assessment

Is your pet currently able to walk?

Unable
Great difficulty
Some difficulty
No problem

How often does your pet show lameness or weakness?

All the time
Occasionally
Rarely
No issues

Does your pet drag their foot when walking?

Which is more noticeable?

Pain
Stiffness
Weakness
All three

Is your pet able to position themselves to urinate?

Unable
Great difficulty
Some difficulty
Easily

Is your pet able to position themselves to defecate?

Unable
Great difficulty
Some difficulty
Easily

Is your pet able to run?

Unable
Great difficulty
Some difficulty
Easily

their walk? home

Is your pet able to jump?

Unable
Great difficulty
Some difficulty
Easily

Does the lameness/weakness affect your pet’s sleep?

Greatly
Sometimes
Maybe
No

Goals & Expectations

What is your primary goal for your pet’s care? (e.g., pain relief, improved mobility, weight loss, chronic disease management, quality of life, etc.)

What is your ideal activity level for your pet? (e.g., normal walks, play at the park, agility, hunting, working dog level, etc.)

How much time can you realistically commit to home exercises and therapy per day/week?

Any other concerns you’d like to discuss?

Functional Questionnaire

Important Information Before Your Visit

Patient Information

Primary Concern

Diet & Lifestyle

Mobility & Function Assessment

Goals & Expectations

Therapies & Programs of Interest

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