Patient Questionnaire
Owner name:
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Patient name:
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Trainer/handler/foster name (if applicable):
Trainer/handler/foster phone number (if applicable):
What is a "normal" activity level for your pet when healthy? (routines, sports, walks/runs, play, etc)
What type of home environment does your pet navigate in or have challenges with? (how many stairs, what type of flooring, etc)
Does your pet have any sensitive areas on his/her body? Please describe:
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Can your pet stand on his or her own?
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Does your pet have a history of seizures?
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Yes
No
Is your pet on any medications or supplements? Please list and include dosage:
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Does your pet have any allergies to medications? Please list:
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Does your pet have any food or other allergies? Please list:
*
Eating Habits
How many meals a day do you feed your pet?
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What kind of food and how much per serving? How is it prepared?
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What kind of treats do you give your pet and under what circumstances?
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Elimination routine
What is your pet’s normal daily routine for elimination (going to the bathroom)?
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Is your pet prone to diarrhea when stressed?
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Yes
No
Is your pet incontient?
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No
Yes, urinary
Yes, fecally
Yes, both urinary and fecally
Play and exercise
What is your pet’s favorite toy?
What is your pet’s favorite game?
Does your pet like chew toys? If so, what kind?
Is your pet indoor or outdoor?
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Totally indoor
Totally outdoor
Both indoor/outdoor
Behavior
How does your pet react to other dogs/cats?
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How does your pet react to unfamiliar people?
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Does your pet ever chew destructively or eat non-food items? Please describe:
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Describe briefly a typical day in the life of your pet so that we can better understand his or her routine:
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Additional medical or behavioral information we should know about your pet:
Submit
Should be Empty: