Canine Rehabilitation Patient History Form
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Name
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First Name
Last Name
Client Email
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example@example.com
Pet Name
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Clinical Signs & Symptoms
What specific symptoms or concerns led you to seek rehabilitation for your dog?
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When did these symptoms first appear?
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Are the symptoms constant or do they come and go?
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Does your dog seem worse after activity or after periods of rest?
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Have the symptoms changed or progressed since they first started?
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Lifestyle & Activity
Before the symptoms began, what were your dog’s usual activities (e.g., walking, running, playing fetch, swimming, hiking, dog sports)? How often did they engage in these activities?
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What activities is your dog currently able to do, and how frequently?
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Has your dog stopped or hesitated to perform any activities recently (e.g., reluctance to walk, avoiding stairs, difficulty jumping onto furniture)?
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What types of surfaces and obstacles does your dog encounter at home (e.g., hardwood or tile floors, stairs inside or outside the home)?
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Medical History
Does your dog have any existing medical conditions, whether related to the current symptoms or not? Have any diagnostic tests been performed in relation to these symptoms (e.g., X-rays, CT scans, MRI)?
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Please list all current medications and supplements your dog is currently taking, including name, dosage, and frequency.
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Diet & Nutrition
What brand and flavor of food does your dog eat?
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How much food does your dog receive per day?
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Please list any additional treats, table food, chews (e.g., dental chews, rawhides) and how often they are given.
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Rehabilitation Goals & Expectations
What are your primary goals for your dog’s rehab program? (For example: returning to a sport or activity, moving without pain, navigating the home independently.)
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In order to create a realistic rehab plan, how often would you be able to bring your dog in for rehabilitation sessions? (e.g., twice per week, once per week, every other week, monthly)
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In order to create a realistic rehab plan, how much time could you dedicate daily to a simple home exercise plan? (Most home exercises take no more than 15-20 minutes per day.)
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