YOUR FIRST VISITFIND OUT HOW REHABILITATION CAN AID YOUR DOG IN HEALING Restoring the health in your dogHome | Canine – Dogs Cats Rehabilitation | Your First VisitFIRST TIME VISIT2017 Form - Pre Consult CUSTOMER INFORMATION First Name * Last Name * Email * Mobile * Address Postal Pet's Information Name of Pet * Breed * Color Age Date of Birth Gender * Male Female Male Neutered Female SpayedVeterinarian Information Name of Clinic * Name of Attending Vet Leave Blank if there are no particular vet Add Another Veterinarian AddVeterinarian Information 2 Name of Clinic * Name of Attending Vet Leave Blank if there are no particular vetPet's BackgroundPlease fill up the below information to help us best plan for homecare Origin of Pet * Breeder - Purchased Breeder - Adopted Pet Store Adopted Shelter | Rescue Home Other Your Pet Is Kept Mostly Indoor Outdoor Both Pet Activity Level Happy Active Normal Depressed Lethargic Other No. of Dogs and/or Cats At Home 12345678910 Type of Food Canned Food Dried Food Home Cooked Brand of Commercial Dog Food Ingredients Used for Home Cook Pet's Allergic Normal OthersPlease list items your pet is allergic to What Is Your Pet Allergic To Pet's Drinking Habit Normal More in the day More between 6pm to 12am More between 12am to 6amPet's Medical HistoryPlease fill up the below information to help us best plan for homecare Would You Like Us To Liase with your Veterinarian for Medical History? Yes No Last Date of Physical Examination If you cannot remember the date, just enter a month of year Deworm in last 12 months Yes No OtherIf unknown, select Others Heartworm Test Yes No Other Flea and Ticks Prevention Yes No Other RECENT Blood test on Kidney & Liver Yes No Other Heartworm Prevention Medication Yes No Other Heart Checking - Ascultation Yes No Other X-Rays in last 12 months Yes No Other Pre-existing Asthma Yes No Other MRI in last 12 months Yes No Other Last Seizure Attack Yes No Other CT Scan in last 12 months Yes No Other Vaccination in last 12 months Yes No Other Ultrasound in last 12 months Yes No OtherPet's Current Mobility ConditionFill help us understand more about your pet's existing condition Able to posture to urinate Yes No Other or Unsure Able to posture to defecate Yes No Other or Unsure Able to Ascend stairs Yes No Other or Unsure Able to Descend Stairs Yes No Other or Unsure Able to walkup inclined hill Yes No Other or Unsure Able to walkdown inclinded hill Yes No Other or Unsure Able to get in and out of a car/truck Yes No Other or Unsure Able to get on and off couch / bed Yes No Other or Unsure Able to run Yes No Other or Unsure Able to jump Yes No Other or Unsure Able to play Yes No Other or Unsure Is Your Dog Able to Go For Walk No If Yes, how far and how long Does Anything prevent your pet from taking longer walks? Yes No Please Explain Why Does your pet have problems with limping, stiffness, dragging legs or difficulty in rising? Yes No Please Explain What caused it and where the limping, stiffness, dragged leg is Does your pet display symptoms of pain? Yes No Please Explain Why and Where Are there any other problems you would like us to know Yes No Please elaborate Share with us your goals and expectations in your pet's physiotherapy sessions?