TheraPaws Initial Consultation
917 West Foothill Boulevard, Upland California 91759 (909) 202-7582
Date
-
Month
-
Day
Year
Date
Pet/Owner Name
First Name
Last Name
Up-to-date on rabies
Please Select
Yes
No
I don't know
Veterinarian
First Name
Last Name
Veterinary Diagnosis
Subjective: Owner(s) Observations, onset, history of injury
General appearance
Type/Breed
Age
Spayed or neutered
Yes
No
Behavior (0-4, score of 0=low and 4=high)
Rows
1-4
Appetite
Mood
Frequency of contact wirh family members
Frequency of tail wagging
Activity
Play and games
Panting
Licking of lips
Vocalization/audible complaining
Vocalization when limbs stretched
Aggressiveness toward humans
Aggressiveness towards other dogs
Aggressiveness toward dogs in its own pack
Submissiveness in the pack
Behavior notes
Home Environment, Baseline Activity Level, Pet's job, Other Pets, General Home Life
Diet, Treats, Medications, Supplements, Other Home Care
Likes, Dislikes, Touch Sensitivity
Onset/Possible Cause of Problem/Injury
Onset/possible cause of problem/injury
Past pertinent medical history
Home environment/Baseline activity level
Diet/medications/supplements
Special tests and results
Body Condition Score (0-9, 9 = obese)
1
2
3
4
5
6
7
8
9
Weight
Muscle condition score (1-4, 1 = marked atrophy)
1 - normal
2 - mild muscle loss
3 - moderate muscle loss
4 - marked muscle loss
Lameness scale at a walk (0-5), 0=Normal
0-Normal
1-Slight, intermittent lameness
2-Obvious weight-bearing lameness
3-Severe weight bearing lameness
4-Intermittent non-weight bearing lameness
5-Continuous non-weight bearing lameness
Lameness scale at a trot (0-5), 0=Normal
0-Normal
1-Slight, intermittent lameness
2-Obvious weight-bearing lameness
3-Severe weight bearing lameness
4-Intermittent non-weight bearing lameness
5-Continuous non-weight bearing lameness
Neurologic Grading (0-5, 0 = normal)
0. Normal
1. Pain, not severe enough to result in any neurological dysfunction
2. Paresis, with or without pain, proprioceptive dysfunction
3. Plegia, total loss of voluntary movement in affected limbs (and/or tail)
4. Plegia with loss of voluntary urinary function
5. Plegia with loss of voluntary urinary function and loss of conscious
perception of painful stimuli (deep pain) in affected limb
Neurological Gait Grading (1-5, 5 = normal)
5 = normal gait and coordination
4 = minimal paraparesis/ataxia: can stand to support
3 = mild paraparesis/ataxia: can stand to support but frequently stumbles/falls
2 = moderate paraparesis/ataxia: unable to stand to support; moves limbs
readily with assistance but stumbles/falls frequently
1 = severe paraparesis: unable to stand; slight movement when supported
Simple Pain Assessment Score
0= no pain
1=signs of mild pain during palpation of joint
2=signs of moderate pain during palpation
3=signs of severe pain during palpation
4-dog will not allow examiner to palpate
Stance Analyzer: weight bearing percentage (left front/right front/left rear/right rear)
Overall stance analysis (0-3)
0- no asymmetry: normal, stands with appropriate weight bearing,
1-mild asymmetry: bears less weight on affected limb or limb trembles
2-moderate asymmetry: puts limb down for balance but bears weight
3-Severe weight bearing asymmetry
Conformation: top line
normal
lordotic
kyphotic
low head carriage
sloped
asymmetric
other (see "Additional Comments")
Conformation: pelvic limbs
normal
straight (Lateral)
over angulation (lateral)
post-legged (lateral)
straight
base wide
base narrow
cow hocked
sickle hocked
down in pastern
toeing in right limb
toeing in left limb
toeing out right limb
toeing out left limb
slipped hocks
reduced weight bearing on left
reduced weight bearing on right
Hold left limb up
holds right limb up
weak weight bearing
knuckled over left
knuckled over right
other (see in "Additional Comments")
Conformation: thoracic limbs
normal
base wide
base narrow
down in pastern
toeing in right limb
toeing in left limb
toeing out right limb
toeing out left limb
reduced weight bearing on left
reduced weight bearing on right
holds left limb up
holds right limb up
weak weight bearing in both limbs
knuckled over left
knuckled over right
scraped nails right side
scraped nails left side
atrophy right side
atrophy left side
camped under
chest too shallow
toeing out, underdeveloped shoulders
overdone shoulders, legs set too far apart
pigeon toes
too narrow, concave chest
down in pastern
other (see "Additional Comments")
General Palpation (Orthopedic and Neurological)
General Palpation
Range Of Motion (functional assessment, pain, comments)
Range of motion
normal
limited range of motion cervical spine - left
limited range of motion cervical spine - right
limited range of motion right shoulder
limited range of motion left shoulder
limited range of motion right elbow
limited range of motion left carpus
limited range of motion right carpus
limited range of motion thoracic spine - left
limited range of motion thoracic - right
limited range of motion lumbar spine - left
limited range of motion lumbar spine - right
limited range of motion hip - left
limited range of motion hip - right
limited range of motion stifle - left
limited range of motion stifle - right
limited range of motion hock - left
limited range of motion hock - right
limited range of motion tarsus - left
limited range of motion tarsus - right
Thigh Girth L/R, Upper Arm L/R
Additional Measurements
Gait Analysis at a Walk
crossover thoracic limbs
crossing over of affected limb(s)
center tracking
shoulder lameness
short stride with pelvic limbs
short stride with thoracic limb
elbow lameness
elbow circumduction
thoracic limb circumduction
pelvic limb circumduction
weight shifted caudally
weight shifted cranially
head bob, head goes down on the sound limb
hindlimbs tucked under
forelimbs placed more caudally
head/neck extend to offset hind end weight
hip hike, increased vertical motion hip on lame side
painful or stiff in one or more limbs
Inability to walk
right pelvic limb weak or ataxic
left pelvic weak or ataxic
reduced conscious proprioception in pelvic limb(s)
reduced conscious proprioception thoracic limb(s)
knuckling right pelvic limb
knuckling left pelvic limb
knuckling right thoracic limb
knuckling left thoracic limb
right pelvic limb incoordination
right thoracic limb incoordination
left pelvic limb incoordination
left thoracic limb incoordination
lameness
unsteadiness
painful walking
limping while walking
arching of the back
lowering of the neck and head
shift in weight
weakness
staggering walk
swaying on feet
wide stance with pelvic limbs spread far apart
wide stance with thoracic limbs spread far apart
inability to extend pelvic limbs during gait
inability to extend thoracic limbs during gait
crouched gait
skipping a stride
shuffling gait
goose stepping gait
loss of balance
stumbling
paw scuffing
loss of movement control
carrying a limb
right pelvic limb paralysis
right thoracic limb paralysis
left pelvic limb paralysis
left thoracic limb paralysis
toe dragging right pelvic limb
toe dragging left pelvic limb
toe dragging right thoracic limb
toe dragging right pelvic limb
crabbing
bunny hopping
Other (see "Additional Comments")
Gait Analysis at a Trot
crossover thoracic limbs
crossing over of affected limb(s)
center tracking
shoulder lameness
short stride with pelvic limbs
short stride with thoracic limb
elbow lameness
elbow circumduction
thoracic limb circumduction
pelvic limb circumduction
weight shifted caudally
weight shifted cranially
head bob, head goes down on the sound limb
hindlimbs tucked under
forelimbs placed more caudally
head/neck extend to offset hind end weight
hip hike, increased vertical motion hip on lame side
painful or stiff in one or more limbs
Inability to walk
right pelvic limb weak or ataxic
left pelvic weak or ataxic
reduced conscious proprioception in pelvic limb(s)
reduced conscious proprioception thoracic limb(s)
knuckling right pelvic limb
knuckling left pelvic limb
knuckling right thoracic limb
knuckling left thoracic limb
right pelvic limb incoordination
right thoracic limb incoordination
left pelvic limb incoordination
left thoracic limb incoordination
lameness
unsteadiness
painful walking
limping while walking
arching of the back
lowering of the neck and head
shift in weight
weakness
staggering walk
swaying on feet
wide stance with pelvic limbs spread far apart
wide stance with thoracic limbs spread far apart
inability to extend pelvic limbs during gait
inability to extend thoracic limbs during gait
crouched gait
skipping a stride
shuffling gait
goose stepping gait
loss of balance
stumbling
paw scuffing
loss of movement control
carrying a limb
right pelvic limb paralysis
right thoracic limb paralysis
left pelvic limb paralysis
left thoracic limb paralysis
toe dragging right pelvic limb
toe dragging left pelvic limb
toe dragging right thoracic limb
toe dragging right pelvic limb
crabbing
bunny hopping
Other (see "Additional Comments")
Gait Analysis
Gait Analysis at a Walk
Gait Analysis at a Walk
Gait Turning Left
Gait Turning Right
Gait Making Circles Left/Right
Conformation at a Sit
Conformation Sternal
Range of motion: functional assessment, pain, and comments
Range of motion (in degrees)
Rows
right flex/ext
left flex /ext
end feel/comments
test position
carpus (32-196)
elbow (36-166)
shoulder (57-165)
tarsus (36-165)
stifle (41-162)
hip (50-162)
Range of motion (in degrees)
Rows
right flex/ext
left flex /ext
end feel/comments
test position
carpus (32-196)
elbow (36-166)
shoulder (57-165)
tarsus (36-165)
stifle (41-162)
hip (50-162)
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Photo and Video Link(s)
Range of Motion (in degrees)
Plan/Recommendations
Massage & Stretch
Cranial Sacral
Underwater Treadmill
Land Treadmill
Floor exercises
Shake Plate
Senior Enrichment
Waist Watchers Program
Cold Laser
Microcurrent
TENS
Pulsed electomagnetic field (PEMF)
thermotherapy
Cryotherapy (if inflammation present)
Acupressure/Acupoint Laser
Home Exercise Program (HEP)
Zoom Group Sessions
Other:
Short-term goals
Long term goals
Goals
Additional information
Examiner's additional notes: preferences, barriers, other
Therapy Plan
Plan of Care for Next Visit
Next Appointment
Examiner's Name
Consultation Conducted by:
Please Select
Jami Waldrop, RVT, CCRP, CERP
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