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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 *

Name *

First

Last

Email *

Pet's Name *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Presenting Complaint

What is the presenting complaint? *

How long has this been going on? *

Was there a history of trauma or inciting cause? *

If yes, please explain *

Has your dog ever had joint trauma or surgery? *

If yes, please explain *

Are symptoms/mobility concerns getting better/worse/staying the same? *

Better
Worse
Staying the same

Please elaborate *

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

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? *

How long? *

Does your dog go to the dog park? *

How frequently? *

Does your dog go to day care? *

How frequently? *

Do you have other dogs at home? *

Do you have stairs in your home? *

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

Does your dog have access to a fenced yard? *

Where does your dog sleep? *

Any other daily or weekly activities your dog participates in?

Response to Rest/Activity

Does your dog’s mobility improve with rest? *

Yes
No
Unknown

Does your dog’s mobility improve with regular exercise? *

Yes
No
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?) *

Response to Treatment

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

Pain medication (NSAIDs, others) *

Helped
No Help
Can't Tell

Supplements *

Helped
No Help
Can't Tell

Acupuncture *

Helped
No Help
Can't Tell

Rehabilitation/Hydrotherapy *

Helped
No Help
Can't Tell

Surgery *

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): *

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

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): *

How many times/ day do you feed? *

Treats (estimated #/day): *

Extras (estimated/ day): *

Allergies to any food: *

Other Medical History

List all surgeries, including spay or neuter, and approximate date: *

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

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) *

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) *

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

Make an Appointment

We proudly serve the pets of Colchester, VT, and surrounding areas. We look forward to seeing you and your pet! To request an appointment, please click the button below.

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Have a Question?

Please complete the form below, and a member of our team will get back to you as quickly as possible.

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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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Email *

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How can we help you? *