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2704 W Michigan St., Duluth, MN 55806
(218) 481-7373
[email protected]
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Home
About Us
Services
Acupuncture
Therapeutic Exercise
Laser Therapy
Therapeutic Ultrasound
Senior Pet Care
Resources
Faq
Online Pharmacy
Contact Us
Schedule An Appointment
Client Portal
Patient Questionnaire
Patient Questionnaire
Newsletter
Patient Name:
Client Name:
Reason for Visit:
Indicate any symptoms (change in activity, weakness, worsening of lameness, etc.) your pet is experiencing. How long has your pet experienced these symptoms?
Describe how your pet has responded to any therapies at this time.
What goals are you looking to accomplish with your pet in physical rehabilitation?
Is your pet under cage rest restrictions? If so, for how long?
Can your pet stand on their own?
When did you last see your referring veterinarian?
Does your pet have a history of seizures? If yes, please elaborate.
1.) Is the patient currently on medications/supplements? (Fill in table below if applicable)
Yes
No
Current Medications and Supplements
Current Medications and Supplement
2.) Has the patient had diagnostics performed, including lab work, radiographs, MRI/CT? (If yes, please send to
[email protected]
, if your referring veterinarian hasn’t already done so.)
Yes
No
Describe diagnostics performed, including lab work, radiographs, MRI/CT
3.) Has the patient had any recent surgery? (Please describe type of surgery and date if applicable)
Yes
No
Describe patient recent surgery
4.) Has the patient received any rehabilitation or acupuncture treatment before? (Please describe if applicable)
Yes
No
Describe any rehabilitation or acupuncture treatment
Does your pet have any allergies to medications? Please list if applicable.
Eating Habits
Current diet (including amount being fed per day):
What type of treats does your pet eat each day, and how many?
Do you give your pet any table scraps? If so, what kinds and how much?
Does your pet have any food allergies? Please list if applicable.
Behavior
How does your pet do with unfamiliar people?
How does your pet do with other dogs or cats?
Has your pet ever required a muzzle for an exam/procedure at the veterinarian before?
Pain and Stiffness
Does your pet have any sensitive areas on his/her body? Please describe.
Do you think your pet is in pain currently? If so, where is he or she painful?
Do you feel your pet is stiff in the morning?
Does your pet’s stiffness seem to resolve or worsen throughout the day? Please describe.
Description of Gait
Does your pet appropriately use all four limbs when
trotting
?
Yes
No
Does your pet appropriately use all four limbs when
walking
?
Yes
No
Does your pet appropriately use all four limbs when
running
?
Yes
No
If no to any of the above, please explain:
Activity and Home Environment
What activities does your pet enjoy doing on a regular basis? How much time is spent doing these activities?
Description of walks and/or
yard time each day:
Description of walks and/or yard time each day:
Distance if walking/running:
Distance if walking/running:
What type of home environment does your pet navigate in? What challenges might they encounter? (How many stairs, what type of flooring, etc.)
Description of Function
Please indicate below if your pet has a problem doing any of the following activities.)
Yes
No
Jumping UP (for example, getting into the car or onto the bed)
Yes
No
Jumping DOWN (for example, getting out of the care or of the bed)
Yes
No
Climbing UP (for example, stairs, ramps, or curbs)
Yes
No
Climbing DOWN (for example, stairs, ramps, or curbs)
Yes
No
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