Pet's Name* Ower Name* Please list current medications and any other medical conditions/injuriesWhat is the history of your pet’s current problem? Include duration of symptoms and dates of injury or surgeryWhat other treatments has your pet received for this problem? When?Has your pet been getting better or worse?What aggravates the problem?What eases the problem?Is the problem/pain affected by time of day or activity? If so, how?Have there been any new playing or working activities introduced to your pet?What commands does your pet follow (i.e. Sit? Heel?)? What is the word you use for “treats”?Does your pet have any food restrictions that limit the treats s/he may have during therapy? (If so, please bring appropriate treats for your pet.)What is your pet’s favorite motivator? (Ball? Treats? Petting?)How many caregivers for your pet are in the home?How difficult are these activities for your pet?Walking No problem A little Quite a bit Severe Impossible Running No problem A little Quite a bit Severe Impossible Jumping No problem A little Quite a bit Severe Impossible Getting up No problem A little Quite a bit Severe Impossible Lying down No problem A little Quite a bit Severe Impossible Climbing stairs No problem A little Quite a bit Severe Impossible Descending stairs No problem A little Quite a bit Severe Impossible Are there any other specific functional challenges your pet is experiencing?What specific goals do you have for your pet’s recovery? (Examples: (1) Climb 4 stairs into home without assistance, (2) Resume jogging 3 miles with me, (3) Regain strength to play with children, (4) Return to hunting.)Phone*Email* EmailThis field is for validation purposes and should be left unchanged.
