Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Preferred method of contact

Phone
Text
Email

Pet's Name *

Species

Canine
Feline

Age/DOB if known

Breed *

Sex *

Male
Female
Neutered Male
Spayed Female

Microchipped

Yes
No

How did you hear about Westside Animal Hospital’s rehabilitation?

Referral from my Veterinarian
Referral from my friend
Internet search
Other

Whom may we thank?

Which platform (Facebook, Google, etc)?

Please Explain:

What specific goals are you seeking for your pet through rehabilitation therapy?

Are you able/willing to perform prescribed exercised at home as part of your pet’s rehabilitation therapy?

Primary complaint:

Duration of problem:

Past treatments for this condition:

Input/Output

Diet:

List specific brand(s)/type canned/dry, amount fed and all treats regularly fed.

Appetite *

Water intake *

Detail food allergies, if applicable:

Urination *

Urine appears *

Stool *

Respiration/Breathing

Breathing *

Normal
Coughing
Has had changes

Please describe changes: *

Has your pet’s “voice” or noises that they typically make changed? Please describe these changes:

Does the condition inhibit activities? If so, what specific activities and when:

Mobility

Does your pet have problems with any of the following? Please check all that apply:

Limps on which limb? *

Explain other: *

When are signs the worst?

Activity level prior to injury:

Does your pet seem in pain? If so, please grade from 1 (mild) to 10 (severe) and when is painful (after walks, upon rising, etc.):

Do you see your pet stretch during the day? Has their stretch changed? Please describe:

Energy & Well Being

Energy level in general: *

Normal
Increased
Decreased

When is energy level the highest? *

When is pet's attitude the best? *

Describe pet's personality:

Does pet prefer:

To be cool
To be warm
No preference

How is pet's sleep schedule?

Describe where your pet sleeps:

Behavior

Has your pet shown behavioral changes recently? If so, please describe:

Have you noticed any irritability? If so, when and under what circumstances:

Has your pet ever demonstrated aggressive behavior? If so, when and under what circumstances:

Medical Information

Current medications – Please list all prescribed and over-the-counter medications including dosage and frequency:

E.g. 100 mg carprofen ½ tablet twice per day

Current dietary supplements & herbal therapies:

Please list all.

History of medical conditions:

E.g. seizures, heart condition, respiratory conditions, surgeries, etc.

Any past history of cancer? If so, what type, when diagnosed, method(s) of treatment:

Home Environment

Check all that apply to your pet’s home environment:

Describe other pets in the home:

Authorizations

Make my pet a social media star! I authorize and grant Westside Animal Hospital Rehabilitation permission to take my pet’s photograph and use it on social media, e.g. facebook, website. Please choose one: *

Yes
No, thank you

Record release: at times your pet’s records may be requested by boarding facilities, groomers, referral or other veterinary practices; do you give permission for Westside Animal Hospital to transmit patient records? *

Yes
No

Veterinarian/practice name:

Veterinarian/practice phone number:

Veterinarian/practice email:

Permission to treat: I hereby authorize the veterinarian at Westside Animal Hospital to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I understand charges are due at the time of service/discharge and that a deposit may be required for treatment. *

Rehab Assessment Form