Owner’s Name:
Phone:*
E-mail *
Address:
How did you hear about us?
Veterinarian(s):
Diagnosis/Problem:

 

PART I: MEDICAL HISTORY

 

General Medical History:

1. Is your dog taking any medications, vitamins, or supplements?
Yes
No
If so:
Please list any surgeries, illnesses, or medical problems and the approximate dates:
Are your dog’s immunizations/vaccines current:
Yes
No
If using titers, are these current:
Yes
No

Current Health Problem(s):

1. Describe the problem(s) concerning your animal companion:
2. When did this begin?
3. How did it happen?
4. Did you witness the accident/incident?
Yes
No
5. Are there any associated symptoms or problems?
Yes
No
If yes, please describe please include when these began.
6. Does your dog limp?
Yes
No
If yes, which limb(s)?
Please grade the limp 1-5. (1 = low/minimal limp 5 = non-weight bearing) Score:
Is there any new play or activity that might have contributed to the problem or that aggravates the problem?
7. Has there been any change in your dog’s sleep pattern?
Yes
No
8. Has your dog been recently evaluated by a veterinarian for this problem?
Yes
No
If yes, please describe the findings and treatment.
9. Has your pet experienced this or a similar problem in the past?
Yes
No
If yes, how was the problem treated?
11. Has your dog been evaluated or treated by any other practitioners or friends?
Yes
No
10. Is your veterinarian aware you are seeking a rehabilitation evaluation and treatment program?*
Yes
No
11. Has your dog been evaluated or treated by any other practitioners or friends?
Yes
No
12. Have any other treatments or interventions been helpful to improve and ease the problem or associated symptoms?
13. What aggravates the problem?
14. Is the problem improved or worsened with exercise?
15. Can you tell if your dog is in pain?
Yes
No
If yes, describe how the pain is manifested in your dog.
please score the pain 1-10. (1 = mild, 10 = severe) Score:
16. Does the dog lay on the affected side?
Yes
No
17. Does your dog need help with positioning or getting up from lie to stand?
Yes
No
Explain:
18. Indicate any gait changes, including such issues as:
Clumsiness
Limping
Difficulty turning
Inability to walk on slippery surfaces
Scissoring gait/crossover
Falling when turning quickly
Other
19. Has there been an increase in any of the following?
Licking
Chewing
Whining
Sluggishness
Restlessness
Flinching
Trembling
Stumbling (esp. w/fatigue)
Other
20. Is this problem worse in the:
21. Are there changes in eating habits?
Are the food bowls elevated?
What food do you feed?
Quantity?
Do you feel that your dog is a good weight?
Yes
No
Does your dog stand to eat?
22. Has your dog experienced any emotional changes as a result of this problem?
Yes
No
If yes, please describe:
23. Are there changes in bowel or bladder habits, such as, difficulty squatting, lifting leg, or incontinence?
Yes
No
If yes, please describe:
24. How does your dog get in and out of the car?
Do you use a dog ramp for furniture or in/out of the car?
Yes
No
25. What kind of bedding does your dog sleep on?
26. Is your dog right or left “handed” (pawed!)? Which paw does digging, scratching at the door or pawing begin with:
Right
Left
Unknown
When running which foreleg most often leads off?
Right
Left
Unknown
27. Is stair climbing or descending a problem?
Yes
No
If yes, please describe
How many stairs must be negotiated?
In the house
Outside
Do you have “doggie gates” at the top and/or bottom of stairs?
Yes
No
28. What type of flooring do you have in the areas the dog walks?
Are there throw rugs?
Yes
No
Are the rugs secured?
Yes
No

PART II: SOCIAL HISTORY

1. Please list other dogs and/or other animals that live with you:
2. Describe the interaction of this dog with the other animals:
3. How many people live at your residence?
Who will provide the home rehab program?
4. Do you have young children that interact with your dog?
Yes
No
If so, please list their ages and describe the interaction:
5. What is your animal’s personality?
Eager to please
Afraid of strangers
Active
Nervous/temperamental
Lethargic
Aloof
Shy
Other
6. Please check any of the following that you and your dog do together.
Companion
Agility
Flyball
Working dog
Obedience trails
Field trails
Hunting coursing
Tracking
Therapy
Other
7. Have there been any recent changes in your daily routine/activities, such as, a recent move, new animals, or new people in your household?
Yes
No
If yes, please describe:

PART III: HABITS

1. What are the common exercise habits/fun that you and your dog shared prior to the current problem?
Swimming
Playing w/tennis balls
Daily walks (how far)
Weekend athlete
Other
2. Describe the current exercise regime:
3. Do you object to utilizing food treats as rewards during therapy sessions?
Yes
No
Does your dog have any food allergies or restrictions?*
Yes
No
If yes, please describe:
4. Are there any behavioral idiosyncrasies? Please check all that apply.
Separation anxiety
Marking
Biting/nipping when certain body parts are touched
Bolting through open doors
Jumping up
Fear or dislike of water
Grabbing food treats aggressively
Growling, snapping/biting at people when near:
Food
Treats
Bones
Toys
Growling at:
People
Other dogs
1. Do you (person) have any physical limitations that need to be considered in forming the rehabilitation plan?
Yes
No
(i.e. back, hip, or knee problems)
2. Currently, how would you describe the quality of life of your companion animal?
3. Please list your rehabilitation treatment goals for your animal companion:
4. What might happen if your dog can not meet these goals?
5. What is the most important issue which I can help you with today?
6. What has been the impact of your dog’s illness/injury on you and your family?

Thank you for your cooperation in completing this information. Your assistance allows us to provide a comprehensive treatment plan, involves you in the care planning, and individualizes the care for the unique needs of your animal companion.

I Agree
Submit Form

ISN'T IT TIME FOR YOUR DOG TO FEEL LIKE A DOG AGAIN?