Client History Questions SSAW - Rehabilitation and Integrative Medicine

Prior to your appointment with our Rehabilitation and Integrative Medicine Department, please complete and submit the following form. Thank you and we look forward to seeing you at your upcoming appointment.

Name*
First Last
Phone*
Pet's Name*
First
Email*
What type is your dog?*
Would you describe your dog as:*
(please check all that apply)
- Friendly
- Nervous
- Aggressive towards dogs
- Aggressive towards people
- Food motivated
- Toy motivated
- Tolerant of new things
- Not good with restraint
- Painful when touched
Is your pet muzzle trained?*
Any allergies?*

(If yes, please list them.)
Any previous medical conditions?*
How did you hear about us?*
Reason for rehab appointment for your pet?*
When did these problems start and how did they present initially?*
How did the problem(s) progress?*
Is the patient limping? Can you describe their gait as toe-touching, non-weight bearing, or partially weight bearing? Do they put weight on their leg at a stand?*
Has there been a change in their working gait?*
Do you have a video?*

If you would like to, please upload your video(s) here.

Do they have trouble making transitions (down to sit/stand or stand to down)? Is this only on specific surfaces?*
Do they have difficulty walking, slipping on, or avoiding slippery floors (hardwood/linoleum/tile)?*
Is there a change in performance working from elevated surfaces (open stairs):*
Are there runners/rugs down to accommodate your pet?*
Does your pet go for walks? How long? How often?*
What is their normal training and conditioning schedule?*
Any additional activity in the home (free roam yard, play with other household pets or children/toys)?*
Any rest, therapy exercises, or devices already started? Ice/Massage? Brace?*
Were these prescribed by a DVM or trainer?*
Any Restrictions?*
(Run, jump, stairs, play?)
Are they using stairs? Alternating steps or bunny hopping? Is down worse than up?*
Do they vocalize abnormally throughout the day or night? Are they sleeping through the night?*
Are they urinating and defecating normally? Any posturing difficulties? Lifting only one leg each time?*
Any change in appetite/eating habits?*
While our records are private and not open to the public, do you have any concerns regarding discretion for this pet?*
We will be taking video to evaluate for gait changes. Is this ok?*
What are the goals for your pet?*
(return to work, retire, hike, play with kids/housemate, companionship)
Any Questions or Concerns:*
Any current medications?
Click the "+" button to add additional medications.
Drug Name Concentration (mg/ml or mg/tablet) Number of tablets or ml per dose Frequency
Additional Supplements/Herbs/Essential Oils?
IF CLICKING SUBMIT BUTTON BELOW DOES NOT DISPLAY SUBMISSION SUCCESSFUL, PLEASE SCROLL UP, CORRECT ANY FIELDS HIGHLIGHTED IN RED, AND TRY AGAIN.

Drug Name	Concentration (mg/ml or mg/tablet)	Number of tablets or ml per dose	Frequency

IF CLICKING SUBMIT BUTTON BELOW DOES NOT DISPLAY SUBMISSION SUCCESSFUL, PLEASE SCROLL UP, CORRECT ANY FIELDS HIGHLIGHTED IN RED, AND TRY AGAIN.