Client History Questions - 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*
How did you hear about us?*
Any allergies or treat restrictions?*

(If yes, please list them.)
Any previous medical conditions?*
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?*
Does the problem occur or become worse at a specific time of day such as after rest or after walks? If so, when?*
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)?*
Are there runners/rugs down to accommodate your pet?*
Does your pet go for walks? How long? How often?*
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?*
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?*
Diet brand/type and how much?*
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.
Phone
This field is for validation purposes and should be left unchanged.

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.