TheraVet Acres Rehabilitation and Fitness Examination Form

First Name

Middle Initial

Last Name

Address

City

State None Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Home Phone

Work Phone

Cell Phone

E-mail

Spouse/Significant Other Name

How Did You Hear About Us?

Pet's Name

Pet's Registered Name

Breed

Birthdate

Male Female

Neutered Spayed

How old was your pet when you obtained?

How old was your pet when spayed/neutered?

Where was your pet obtaind from?

Referring Veterinarian

Referring Veterinarian Practice

Years You Have been Going There

OFA/Penn Hip Status

Allergies

Pet Motivated by (food, toys, etc)

Type of Food given (including snacks/treats)

Quantity of Food

When Fed

Supplements given (with amounts)

Medications given (with amounts)

Does your pet have any major medical issues (past and/or present)?

Has your pet undergone any surgical procedures (what and when)?

Reason for seeking our services

Duration and progression of current signs

Previous treatments and outcomes

Is the condition worse with Hot Day Cold Day After Exercising After Resting/Sleeping Wet Weather Unknown

Does your pet have any daily life restrictions caused by this condition?

Have you noticed anything that aggravates this condition?

Have recent x-rays, blood work or other diagnostics been performed for this current condition?

Please list your goals for therapy

What type and quantity of exercise does your pet do on a daily and weekly basis?

Is your pet walked using Head Harness Body Harness Collar Flexi-Lead Fixed-Lead

Does your pet participate in any of the following? Agility Fly-Ball Obedience Conformation Freestyle Hunt/field tests Earthdog tests Tracking Shutzhund Herding Lure coursing Flying Disc CaniCross/Skijoring Rally Obedience Dock Dog Working Other

Do you have stairs that your pet must go up/down? How Many?

Where are the stairs? Inside Outside

Are the stairs carpeted? Yes No

Does your pet have difficulty going up/down these stairs? Yes No

What type of flooring do you have in your house?

Does your pet prefer to sleep on soft or hard surfaces? Hard Soft

Does your pet prefer hot or cold places to sleep/lie down? Hot Cold

Does your pet have difficulty getting in and out of the car? Yes No

Do you have a ramp? Yes No

Do you have a fenced_yard? Yes No How Big?

Does your pet have access to a dog door? Yes No

Do you have other pets? (please list)

Which of our services are you interested in? Acupuncture Chiropractic LASER Therapeutic Massage Pulsed Signal Therapy Therapeutic Exercises Land Treadmill Underwater Treadmill Hako-Med Whirlpool Sports Medicine Boarding Weight loss program Puppy program All of the above

Have you had acupuncture done on yourself or any of your pets previously? Yes No

Have you had chiropractic done on yourself or any of your pets previously? Yes No

Do you give Dr. Browne permission to perform gentle, hands only, spinal manipulations to your pet during the initial examination if she feels that it will be beneficial? Yes No

Please give us any other information that you feel could be beneficial to us in helping your pet: