Rehab/Acupuncture 1st Visit History Form
Thank you for filling out this form and helping our staff prepare for your visit.
Your pet's name
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Your Full Name
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First Name
Last Name
Cell phone number where we can reach you during your appointment
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Format: (000) 000-0000.
Date of Your Scheduled Appointment
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Month
-
Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your pet currently taking any medication, parasite prevention, supplements, or vitamins?
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Yes
No
Please list all medications, parasite preventives, supplements, and vitamins your pet is currently taking.
We often use treats during rehab and acupuncture treatments. Does your pet have allergies to any medication, vaccine, or foods?
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Yes
No
Can your pet have our treats while here (may include liver treats, EasyCheese, etc).
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Yes, any treats are fine
No, my pet has treat restrictions (please note below)
Please list all of your pet's known allergies or treat restrictions:
Please list the type, brand, and amount of foods your pet receives. Please include treats.
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Does your pet need any medication or prescription diet refills today?
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Yes
No
How did you hear about rehab/acupuncture at Atlantic Veterinary Hospital?
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Current Atlantic Veterinary Hospital patient
Referral from regular veterinarian (please note veterinary clinic below)
Referral from a specialty veterinary hospital (please note specialist below)
Internet search/Drive by/Own research
Name of regular veterinarian or specialty hospital if noted above:
Why are you seeking a rehab, pain, and or acupuncture consultation? What signs are you seeing at home?
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Are you interested in (or would like to learn more about):
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In-hospital rehab treatments
Home rehab exercises
Acupuncture treatments
Laser treatments
Medications, supplements, and/or diets
Other
What is your pet's current level of activity? (length of walks/activity, on leash vs off leash activities, etc)
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What are your goals for treatment? This could involve pain control/comfort, return to specific activities or tasks, etc
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Please check all symptoms that your pet is currently experiencing. Explain in the space below. During a specific rehab or acupuncture appointment we may not be addressing additional issues, but recommendations may change if there are certain concurrent problems.
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Vomiting (frequency?)
Diarrhea
Constipation
Sneezing
Coughing
Decreased mobility
Lameness or limping
Lethargy
Appetite changes (please describe below)
Increased water drinking
Increase urination amount or frequency
Urinary or stool accidents in the house
Eye problems
Skin and/or ear problems
Behavioral changes (please describe below)
Mouth or tooth problem
Concerns about pet's weight (increase or decrease)
None, my pet seems healthy and I have no concerns
Please provide details about your concerns (duration, frequency, severity, etc.). List any additional information you feel may be helpful to the doctor.
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