Initial Comprehensive History
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Owners Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
How did you hear about us?
What is the name of your primary veterinarian/clinic name?
Pets name
Pets Name
Age/Date of Birth
Breed
Sex: Male, Female or Neutered,male/Spayed,female
What is the name of your primary veterinarian/clinic name?
Diagnosis/problem
General Medical History
1. Is your pet taking any medications, vitamins, or supplements? If so:Please list all Products:
2. Please list any surgeries, illnesses, or medical problems and the approximate dates:
Describe the problem(s) concerning your animal companion:
5 How did it begin?
5 How did it happen?
5 Does your pet limp?
If yes, which limb(s)?
Please grade the limp 1-5. (1 = low/minimal limp; 5 = non-weight bearing) Score:
Is there any activity that might have contributed to the problem or that aggravates the problem?
7. Has your pet experienced this or a similar problem in the past?If yes, how was the problem treated?
8. Has your pet been evaluated or treated by any other practitioners?
9 Have any other treatments or interventions been helpful to improve and ease the problem or associated symptoms?
10 Is the problem improved or worsened with exercise?
11. Can you tell if your pet is in pain?
If yes, describe how the pain is manifested in your pet.
If your pet has pain please score the pain 1-10. (1 = slight, 10 = severe) Score:
12. Does your pet need help with positioning or getting up from lie to stand?
13. Has there been an increase in any of the following?Licking, Flinching, Trembling, Stumbling (esp. w/fatigue), Limping or inability to walk on slippery surfaces? Other?
If yes, please explain.
14. Is this problem worse in the: Morning, afternoon or evening?
Please explain
15. Are there changes in eating habits?
a) Are the food bowls elevated?
b) What food do you feed?
c) Quantity? How often?
d) What treats do you give if any?
e) Do you feed people food?
f) Do you feel that your pet is a good weight?
g) Does your pet stand to eat?
16. Are there changes in bowel or bladder habits, such as, accidents, difficulty squatting, lifting leg, or incontinence?
17. How does your pet get in and out of the car?
19 What kind of bedding does your pet sleep on?
20 Are there any stairs that that your pet needs to use?
21 What type of flooring do you have in the areas where the pet walks?
22. What is your animal's personality? Eager to please, afraid of strangers, active, nervous/temperamental, lethargic, shy or other?
23. What are the common exercise habits that you and your pet shared prior to the current problem? SwimmingPlayingDaily walks (how far)Weekend athlete
24. Does your pet have any food allergies or restrictions?
If yes, please describe * If allergic/restricted please bring alloweable treat to the therapy sessions.
25. Are there any behavioral idiosyncrasies? Please note below.
Fear, dislike of water, separation anxiety, biting or nipping at body parts, fear of people or other pets, any noise phobias?
a) Any sensitive body parts? (i.e. feet, tail, face, etc)
b) Growls, snipping/biting at people when near? (food, treats, bones or toys)?
c) Growls at people or dogs?
26. Are you willing and able to assist your pet in a prescribed physical exercise program at home? Should be no more than 15 minutes of your time.
27. Currently, how would you describe the quality of life of your companion pet?
0 (very poor) to 10 (excellent)
28. Please list your rehabilitation treatment goals for your pet:
29 What might happen if your dog can not meet these goals?
30 What is the most important issue which can help you with today?
31 What has been the impact of your dog's illness injury on you and your family?
32 What current daily activity has been challenging to your pet?
Please mark appropriate response
Rows
Excellent
Good
Fair
Poor
Appetite
Mood
Contact with people
Frequency of tail wagging
Activity level
Sleeping pattern
Walking
Trotting
Galloping/running
Jumping
Climbing stairs
Descending stairs
Laying down
Getting up
Difficulty moving after rest
Difficulty moving after activity
Type a question
Rows
Never
Infrequent
Frequent
Very frequent
Excessive panting
Pacing aimlessly
Licking lips
Vocalization
(audible complaining)
Aggressiveness towards
people
Aggressiveness towards
dogs
Clients full name (Electronic signature)
Submit
Should be Empty: