Pet's Name *

Client Name *

First

Last

Phone *

Email *

Main Concerns

What concerns you most about your dog’s mobility?

How long has this been going on?

Was there an injury or known cause?

Yes
No

If yes, explain

Is your dog

Improving
Worsening
Staying the same

Any past joint injury or surgery?

Yes
No

If yes, explain

Mobility & Behavior Changes (Check all that apply)

Daily Activity

Daily walks *

Yes
No

Duration

Other activities (park, daycare, etc.)

Home Environment

Stairs
Slick Floors
Fenced Yard
Other Pets

Where does your dog sleep?

Treatments Tried

Have you tried any of the following?

Treatment

Other

Current Medications and Supplements

Please list all 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.)

Diet and 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)

What Motivates Your Pet?

What basic commands does your dog follow?

What motivates your pet? (affection, treats- explain)

Rehabilitation & Integrative Care Consent *

I authorize Cascade Summit Animal Hospital to perform a rehabilitation evaluation and provide integrative therapies as recommended for my pet. I understand these may include (but are not limited to) therapeutic exercise, manual therapy, laser therapy, acupuncture, and/or other rehabilitation modalities. I understand that treatment recommendations will be based on my pet’s condition and may be adjusted as needed for safety and response.

Client Signature *

Clear Signature

Date *

Rehabilitation First Consult Form

Fill Out The Form