TheraPaws Initial Consultation
917 West Foothill Boulevard, Upland California 91759 (909) 300-5264
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
General appearance
Type/Breed
Age
Spayed or neutered
Please Select
Yes
No
Behavior (0-4, score of 0=low and 4=high)
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
Additional behavior notes
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)
Please Select
1
2
3
4
5
6
7
8
9
Weight
Muscle condition score (1-4, 1 = marked atrophy)
Please Select
1
2
3
4
Lameness scale at a walk (0-5), 0=Normal
Please Select
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
Please Select
Neurologic Grading (0-5, 0 = normal)
0-walking normally
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
Simple Pain Assessment Score
Please Select
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 for dogs over 25 lb/12 kg : weight bearing % left front/right front/left rear/right rear
Overall stance analysis (0-3)
Please Select
0=normal, stands with appropriate weight bearing
0-no asymmetry
1-mild asymmetry,bears less weight on affected limb or limb trembles when standing
2-moderate asymmetry,puts limb down for balance but bears weight
3-Severe weight bearing asymmetry
Conformation: top line
lordotic
kyphotic
low head carriage
sloped
asymmetric
other (see additional comments)
Conformation: pelvic limbs
straight (lateral)
over angulation (lateral)
post legged (lateral)
straight
base wide
base narrow
cow hocked
sickle hocked
bow hocked
sickle hocked
down in pastern
slipped hocks
weak weight bearing
other (see additional comments)
Conformation: thoracic limbs
camped under
out at the elbows
restricted at the elbows
chest too shallow crooked at the wrist
toeing out, underdeveloped shoulders, too narrow
overdone shoulders, legs set too far under body
pigeon toes
too narrow, concave chest
down in pastern
other (see additional comments)
General Palpation
Circumference of limbs (LF, RF, LR, RR)
Additional Measurements
Range of motion (in degrees)
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)
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: functional assessment, pain, and comments
Gait Analysis
Video
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Photographs
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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
Short-term goals
Long term goals
Additional information
Examiner's additional notes/preferences/barriers
Plan of Care for Next Visit
Next Appointment
Examiner's Name
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