Animal Health Record
Owner Information
(tell us about you, human)
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
*
Friend/Family
Social media
Google
Other
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Animal Information
Please fill out the following questions as completely as possible. If not applicable, please write NA.
Animal Name
*
Birthday
-
Month
-
Day
Year
Date
Type of Animal
*
Dog
Cat
Horse
Livestock
Rabbit
Other
Breed
Please list your animals colors/markings.
Gender
Male
Female
Is your animal spayed/neutered?
Yes
No
Is your animal up to date on their rabies vaccinations?
*
Yes
No
Please list all medications your animal is currently taking and what they are being used for:
*
Please list all supplements your animal is taking and what they are used for:
*
Please list any special diet your animal is on:
*
Please describe your animal’s daily activities and energy levels on a normal basis:
*
Please list any behavior that is unique to your animal that the doctor should be aware of (nervous around fast motions or loud noises, bites if get near paws, etc) that could help her make a better connection with your animal:
*
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Complaint History
Please fill out the following questions as completely as possible. If not applicable, please write NA.
What is the reason for today's visit?
*
When did the condition(s) begin? (write unknown if you don't know)
Please describe the onset of the condition/ how it started (i.e. unknown, gradual, out of the blue, injury induced, work related, auto accident, etc):
Has your animal had this condition previously?
Yes
No
Since the onset, the condition(s) is:
Improving
Not changing
Getting worse
When is the condition(s) at its worst?
Morning
Mid-day
Afternoon
Evening
Night
It is constant
What has changed since the condition(s) began? (select all that apply)
Poop frequency
Poop consistency/amount
Urination frequency
Urination consistency/amount
Increased rest
Decreased energy
Not putting weight on one or more legs
Falling/ collapsing
Decreased miles for walks
Decreased activity
Refusal to eat
Decreased appetite
Decreased water intake
Increased thirst
Other
What makes the condition(s) worse/ aggravates them? Please describe when necessary.
What makes the condition(s) better/ relives them? Please describe when necessary.
Please describe other practitioners and/or other treatments your animal is seeing or undergoing for the condition(s):
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Medical History
Please fill out the following questions as completely as possible. If not applicable, please write NA.
Please list all healthcare practitioners (veterinarian, massage therapist, chiropractor, rehab specialist, etc) your animal has seen in the past and for what condition, if any. Please include any results and complications:
*
Please list all your animal's current medical conditions and what treatment being received:
Please list all your animal's previous medical conditions and what treatment was received:
Please list any hospitalizations your animal has had in the past (include length of stay, what was done, and why):
Please list all medications previously given to your animal:
Please list all vaccinations previously given to your animal:
*
What imaging has your animal had in the past? (select all that apply)
Xrays
CT scan
MRI
Ultrasound
Other
Please list any history of physical injury your animal has had (includ any treatment received):
*
Please list any history of surgeries (include rehab/follow up treatment received and any complications):
*
Please list other information you think the doctor needs to know about your animal's health:
*
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Authorization of Care
I recognize and understand that Dr. Brittany Freese, DC, CVSMT is a Minnesota State licensed Doctor of Chiropractic with Certification in Veterinary Spinal Manipulative Therapy from the Healing Oasis Wellness Center, and Animal Chiropractic Registration in the State of Minnesota. She is not a Veterinarian and therefore will not take responsibility for the primary health care of my animal. Chiropractic care is NOT intended to replace traditional Veterinary care, but is a complementary therapy that is to be used in conjunction with primary Veterinarian care. I hereby authorize Connect Animal Chiropractic, LLC, and in particular, Dr. Brittany Freese, DC, CVSMT, to treat my animal with animal chiropractic.
Signature
*
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Certification of Veterinarian
I certify that my animal has had routine, traditional veterinary care, and my current veterinarian is:
Veterinary Clinic Hospital Name
*
Name of Veterinarian doctor (if specific)
*
Veterinarian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Signature
*
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Media Release
Connect Animal Chiropractic has my permission to use my animal’s picture and first name on social media sites operated by Connect Animal Chiropractic.
Signature
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