Synovetin OA Screening Questionnaire - Veterinary Specialty Center

Owner Name(Required)

First Last

Pet Name(Required)

First

Person Interviewed(Required)

First Last

Date(Required)

Household members:

Gender

Age

Describe each household member’s interaction(s) with your dog as direct, close and intermediate activities. Direct activities are <1ft (e.g., carrying the dog where the elbow is in contact or lap sitting where the elbow is directly on the torso). Close activities are at 1ft (e.g., feeding, grooming, sleeping, and routine lap-sitting) Intermediate activities are at 3ft (e.g., walking, jogging, and officing).

Household Member 1:(Required)

Please list any activities and the type of contact involved (direct, close or intermediate):

Duration (hours, minutes, etc.):

Household Member 2:

Please list any activities and the type of contact involved (direct, close or intermediate):

Duration (hours, minutes, etc.):

Household Member 3:

Please list any activities and the type of contact involved (direct, close or intermediate):

Duration (hours, minutes, etc.):

Household Member 4:

Please list any activities and the type of contact involved (direct, close or intermediate):

Duration (hours, minutes, etc.):

Answer the questions below. Any No* checkmark may be contraindicated for the procedure. Contraindication is based on caretaker responses, proposed dose to pet, or other clinical factors.

Can interactions with children and pregnant women be modified to minimize close contact with the dog?(Required)

Yes

N/A

Hidden

If the answer to the above question is yes, describe proposed modifications:

Does your dog currently sleep in the same bed with any household members?(Required)

Yes

N/A

Since you answered YES above, can arrangements be made to avoid this for the duration indicated on the Release Instructions?(Required)

Yes

N/A

Hidden

If the answer to the above question is yes, describe proposed modifications:

Is your pet mobile enough to climb stairs and/or enter and exit a vehicle independently?(Required)

Yes

N/A

Hidden

If the answer to the above question is no, provide the owner with additional strategies:

Does your dog jump up to beds or furniture with family members, or lap sit?(Required)

Yes

N/A

Hidden

If yes, can arrangements be made to avoid this for the duration indicated on the Release Instructions (i.e., not lap sit)? Describe proposed modifications:

Does your dog currently sit in very close proximity (i.e., next to your chair or at your feet) to you for more than 3 hours per day?(Required)

Yes

N/A

Hidden

If yes, can arrangements be made to avoid this for the indicated time frames on the Release Instructions? Describe proposed modifications:

Hidden

Has the owner been provided with an example Release Instructions sheet?

Hidden

Does the owner fully understand the procedure they have arranged for their pet?

Hidden

Are the household members able and willing to modify your routine interaction with your pet for the time frames indicated on the Release Instructions?

Hidden

If the answer to the above question is yes, describe proposed modifications:

By signing below, I acknowledge I fully understand the radiation safety aspects associated with Synovetin OA®.

Name(Required)

First Last

Signature(Required)

Date(Required)

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