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Orthopedic History Form

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Orthopedic History Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Today's Date(Required)

MM slash DD slash YYYY

Name(Required)

First Last

Email(Required)

Phone(Required)

Pet Information

Pet Name(Required)

Breed(Required)

Age/Date of Birth(Required)

Sex(Required)

Male

Neutered Male

Female

Spayed Female

Presenting Complaint

How long has this been going on?(Required)

Does pet swim or contact pond, lake, stream or puddle water or travel on pasture land?(Required)

Was there a history of trauma or inciting cause?(Required)

Yes

Has your dog ever had joint trauma or surgery?(Required)

Yes

Are symptoms/mobility concerns getting better/worse/staying the same?(Required)

Better

Worse

Staying the same

Please elaborate(Required)

Have you noticed any of the following (check all that apply):(Required)

Change in sleeping habits (sleeps more/is restless/can’t get comfortable)

Change in elimination habits (change in posture to urinate/defecate/accidents in house)

Change in behavior (more reclusive/new aggression towards people or other dogs)

Difficulty lying down

Difficulty getting up

Difficulty jumping up (in the car/on the bed/on the couch)

Difficulty going up stairs

Difficulty going down stairs

Change in tail position/wagging (holds tail lower)

Increased appetite

Decreased appetite

Vomiting

Diarrhea

Coughing, sneezing

Straining to urinate or defecate

Change in the sound of bark

Gagging/wheezing/honking sounds

Any new lumps or bumps that are growing quickly

None of the above

Activities of Daily Living

Does your dog go for a walk every day?

Yes

Does your dog go to the dog park?

Yes

Does your dog go to day care?

Yes

Do you have other dogs at home?

Yes

Do you have stairs in your home?

Yes

Do you have slick floors (hard wood/tile/laminate) in your home?

Yes

Does your dog have access to a fenced yard?

Yes

Where does your dog sleep?(Required)

Any other daily or weekly activities your dog participates in?

Response to Rest/Activity

Does your dog’s mobility improve with rest?(Required)

Yes

Unknown

Does your dog’s mobility improve with regular exercise?(Required)

Yes

Unknown

What makes your dog’s mobility better or worse? (Is your dog more sore first thing in the morning then warms out of it? Becomes lame after a long walk or play?)(Required)

Response to Treatment

Have any of the following treatments been tried and did they help your dog’s mobility?

Pain medication (NSAIDs, others)(Required)

Helped

No Help

Can't Tell

Supplements(Required)

Helped

No Help

Can't Tell

Acupuncture(Required)

Helped

No Help

Can't Tell

Rehabilitation/Hydrotherapy(Required)

Helped

No Help

Can't Tell

Surgery(Required)

Helped

No Help

Can't Tell

Other Treatments

Current Medications and Supplements

Current medications (include all supplements, parasite prevention, over the counter and prescription). Please also include frequency of administration and date of last dose(s):(Required)

Allergies to any medication (vomiting, diarrhea, change in appetite, sedation, etc.): List medication and reaction(Required)

Diet & Nutrition

Please list all sources of calories that your dog receives. It is OK if they get treats or “people food,” please just let us know so we can take into account for nutritional recommendations.

Primary Diet (indicate if kibble, canned, fresh cooked, freeze dried, raw):(Required)

How many times/ day do you feed?(Required)

Treats (estimated #/day):(Required)

Extras (estimated/ day):(Required)

Allergies to any food:(Required)

Other Medical History

List all surgeries, including spay or neuter, and approximate date:(Required)

List any previous medical history including any hospitalization or treatments (examples: seizures, bladder infection, pancreatitis)(Required)

Goals

What is your ideal level of exercise or activity for your dog? (Examples: able to play at the dog park without being sore, able to go for a walk without limping, able to hunt or participate in agility competitions)(Required)

Realistic Expectations

We will customize a plan specific for YOU and YOUR DOG. To do so, we must set realistic goals and expectations. Please know that there are absolutely no right or wrong answers here, we just want to work with you to design a program that can be carried out and maintained long term.

Realistically, what concerns do you have for carrying out a home program that may include walks, exercises, diet, administering medications, change in routine? (Examples: time restrictions, other dog in house, young children, cost)(Required)

Describe any other goals or concerns regarding pain management and mobility that you would like to discuss.(Required)

Signature(Required)

Comments

This field is for validation purposes and should be left unchanged.

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Location

5866 Roosevelt Highway
Colchester, VT 05446

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Contact Information

P: 802-878-3713
E: contact@petitbrook.com

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Hours

Mon-Fri: 8:00 AM-5:00 PM
Sat: 8:00 AM-12:00 PM
Sun: Closed

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