Patient Questionnaire

Owner name:*

Patient name:*

Trainer/handler/foster name (if applicable):

Trainer/handler/foster phone number (if applicable):

Has has your pet had any imaging for the issues we are seeing them for? This includes radiographs, MRI, CT etc- if so, when, and at what clinic(s)?*

If your pet has recently had surgery, please detail the type of surgery, facility where the surgery took place, and the date of the surgery (put NONE if not applicable):*

YesNo

What is a "normal" activity level for your pet when healthy? (routines, sports, walks/runs, play, etc) What is their current level, if different?*

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:*

Does your pet have a history of seizures? If yes, please elaborate in the additional medical information *

Is your pet on any medications or supplements? Please list and include dosage: *

Does your pet have any allergies to medications? Please list:*

Does your pet have any food or other allergies? Please list:*

What kind of food do you feed your pet and how often?*

What kind of treats do you give your pet and under what circumstances?*

Is your pet prone to diarrhea in stressful situations? If yes, please elaborate *

How does your pet react to other dogs/cats? *

How does your pet react to unfamiliar people? *

Describe briefly a typical day in the life of your pet so that we can better understand his or her routine:*

Any other medical or behavioral information that is important about your pet? Please put N/A if none.*

Patient Questionnaire

Eating Habits

Behavior