Owner's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your Spouse or Partner's Name

First Name

Last Name

Referral *

Were you:

referred by another veterinarian

not referred by your veterinarian

How did you hear about us? *

veterinary referral

recommendation from a coach or instructor

recommendation from a friend

website

internet search

social media

other

Sex *

male

neutered male

female

spayed female

Rabies Vaccination *

Has your pet been vaccinated for rabies?

yes

no

unknown

Other Vaccinations *

Has you pet had any other vaccinations?

yes

no

unknown

Experience with Vets *

How would you best describe your pet’s reaction to being examined by a veterinarian? (check all that apply)

friendly/happy to be touched by anyone

nervous but co-operative

better with treats

very stressed or nervous – special care needed

can sometimes get snippy – bare teeth or give warning growls

has had to be muzzled in the past for safety reasons

Reason for Visit *

Are you here to address:

active lameness, weakness or pain

general decrease in athletic ability/performance

preventative medical or wellness appointment

Expectations *

What are your current or future athletic expectations for your pet?

competition/working dog

very athletic lifestyle (mountain biking, ski touring, multi-day hikes etc.)

active lifestyle – frequent walks, running in park, day hikes etc

casual lifestyle – mostly hangs out with people or in the house

old/debilitated from ongoing issue – just want my pet to be comfortable

Region *

Which region is affected?

right front leg

right hind leg

left front leg

left hind leg

back end

front end

back or neck

other

History *

Since you first noticed it, has the issue:

gotten better

become worse

stayed the same

Current Status *

Is this issue:

constant

intermittent

worse during exercise

worse after rest/getting up from a nap

wellness appointment (no issue/prevention assessment)

other

Movement *

Does your pet have difficulty with:

jumping up (into car etc.)

jumping down

going upstairs

going downstairs

getting up from lying down

lying down

worse on certain types of footing

worse with certain activities

none of these

Has your pet been diagnosed with a neurologic issue? *

yes

no

Does your pet suffer from seizures? *

yes

no

Does your pet have a history of urinary incontinence? *

yes

no

Does your pet suffer from faecal incontinence? *

yes

no

Does your pet suffer from unco-ordination or staggering? *

yes

no

Has your pet ever had an adverse drug reaction? *

yes

no

Was this issue brought about by any specific event? *

yes

no

Does this issue cause sudden sharp pain or screaming? *

yes

no

Does this issue shift between multiple locations? *

yes

no

not sure

Is your pet on supplements? *

eg: glucosamine or essential fatty acids

yes

no

Is your pet on non-prescription anti-inflammatory medications? *

eg: aspirin, Tylenol

yes

no

Is your pet on prescription medication from your veterinarian? *

yes

no

Is it OK to feed dehydrated beef liver treats? *

yes

no

Is it OK to feed cheese based crunchy treats?

yes

no

Photos *

We also sometimes post pictures of patients on our Facebook page, but would never do so without your permission

yes, I give permission to post pictures and first name of my pet on your Facebook or other social media pages

no, please do not post pictures of my pet