Patient History Form

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?

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24 Hour Emergency & Critical Care

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