New Patient Information Form

New Patient Questionnaire

Please complete to the best of your knowledge. The more information we have the more we can tailor treatment to your pet. Please return the form at least 24 hours prior to your scheduled appointment.
Client information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred communication
Veterinary Care Team
Name of primary veterinarian

First NameLast Name
Primary/Regular Veterinary Hospital
Other doctors or practitioners and their clinics names that are involved in your pets care.
Please include osteopath/rehab/chiro/acupuncture/second opinion vets
Patient information
Name
Species
Breed
Colour
Age/ Date of birth if known
Weight
Gender
Neutered/Spayed
Microchipped
Is your pet insured?
If yes please provide the insurance company name and policy number.
Have you had your pet since they were young/do you know their full medical history?
If no please provide approximate dates of adoption and any relevant past history such as country of origin
Medical Information
Primary complaint
Duration of condition/problem
Other medical history (i.e. seizures, heart conditions, respiratory conditions,surgeries, etc.)
Does your pet have any past history of cancer? If yes, please indicate what type of cancer, when they were diagnosed, and how they were treated
Current medications (please list all prescribed and over the counter medications including dosage and frequency given)
Current dietary supplements and herbal therapies (please list all including dosage and frequency given)
Past treatments for this condition
Current diet
Commercial diet. Please provide details of brand, wet/dry and amount and frequency fed.
Home prepared. Please provide quantity and ingredients, raw or cooked and frequency fed.
Please list all treats that your pet receives and how often
Does your pet have any food allergies or are there certain treats that they cannot have? *We often use treats to reward and motivate pets during their assessments and treatments*
How is your pets appetite?

Other
How is your pets water intake?

Other
How is your pets urination?

Other
How are your pets stools?
Please describe your pet's skin/feet/nails? (Normal/dry/oily/flakey/overgrown/matted)
Does your pet have problems with any of the following? Click all that apply:

Other
When are your pets symptoms worse?
Do you think your pet is painful. Please select the level of discomfort you feel they are in

1

2

3

4

5

6

7

8

9

10

1 is Normal/No pain, 10 is Severe pain
Describe your pets current activity include duration, distance, effort and terrain
Activities and level prior to this complaint/injury/condition

Other
Describe your pets current activity include duration, distance, effort and terrain. For dog sports how often you train etc
Please describe your pets home environment

Other
Do you see your pet stretch during the day
If yes has the way they stretch changed?
In general how is your pets energy level
When is your pets energy level at its highest?
How is your pets sleep schedule
Where does your pet sleep?
Please describe your pets personality
When is your pets attitude at its best?
Has your pet had behavioral changes recently? If so, please describe
Have you noticed any irritability in your pet? If so, when and why?
Has your pet ever demonstrated any of the following behaviors in any situation?
If you have selected any of the above, please describe the situation in detail. (Please be very honest; it is for our staff’s safety and to ensure we do not do anything to trigger your pet and make their visit stressful):
Treatment planning, goals and expectations
What are your specific goals that your are hoping to achieve with rehabilitation? (examples: weight loss, reduced discomfort, return to competitive sport, ability to do short walks, improved quality of life. Please list all so we can discuss and plan accordingly)
Are you able/willing to do prescribed exercises at home as part of your pet's rehabilitation therapy?
If yes how often could you do your pets prescribed exercises?
Rehabilitation is not a instant fix and requires regular sessions/revisits as well as, consistency outside of sessions, to enable improvement. The treatment plan will be adjusted to your pet and your abilities as much as possible. Are you able to commit to a regular schedule for visits and to follow a structured treatment plan
DISCLAIMERS AND CLIENT CONSENT
Fur Ability Animal Rehabilitation Inc. requires a signed Veterinary consent treatment form, full medical records from your General Practice Veterinarian and any diagnostics that have been performed to be sent to us prior to your initial consultation. If these have not been received prior to your initial consultation date, then your consult may need to be rescheduled.
Fur Ability Animal Rehabilitation Inc. are not legally allowed to diagnose a condition or perform diagnostic tests or radiograph. If these are recommended, you will have to return to your general practice veterinarian to have them performed.
Fur Ability Animal Rehabilitation Inc. can only work via referral from your veterinarian. Without this no treatment can be performed. Your pet is being assessed for a rehabilitation program and treatment plan. If you have any other health concerns about your pet, they will need to be addressed by your general practice veterinarian. If other concerns arise during treatment Fur Ability Animal Rehabilitation Inc. will refer you back to your veterinarian and treatment may have to be delayed until they are assessed and cleared for treatment again.
Short notice cancellations are costly and deprive those waiting of an opportunity to be seen. We have a cancellation fee of $75.00 if the consultation is cancelled with less than 2 business days’ notice (Mon-Fri). If the consultation is cancelled on the day of the consultation or you fail to attend, then the cancellation fee is $150.00. Please contact us if you require more information on the cancellation policy. This fee will have to be paid in advance of further treatment and multiple short notice cancellations could result in dismissal from Fur Ability Animal Rehabilitation Inc.
And lastly on a fun note! I'd love my pet to be famous! I grant Fur Ability Animal Rehabilitation Inc. permission to take picture's of my pet and use it on social media
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New Patient Questionnaire

Client information

Veterinary Care Team

Patient information

Medical Information

Treatment planning, goals and expectations

DISCLAIMERS AND CLIENT CONSENT