New Patient Form | Animal Rehabilitation Facility

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Services
About
For Veterinarians
Premium Products
Exercise Program
News
ARF Fit Club
Contact

New Patient Form

Today's Date*
MM slash DD slash YYYY
Client (Owner) Name*
Prefix First Last
Spouse/Partner Name
Prefix First Last
Address
Street City State ZIP Code
Home Phone
Business Phone
Cell Phone
Spouse/Partner Phone
Email
How Would You Prefer to be Contacted
- Select All
- Home Phone
- Business Phone
- Cell Phone
- Spouse/Partner Phone
- Email
How did you find out about Animal Rehabilitation Facility
- Referral from my veterinarian. Please list your veterinarian's name below.
- Referral from a friend/family member.
- Found on the Internet (Google search, Facebook, etc)
Other
Veterinarian Information
Referring Veterinarian
Veterinarian's name Clinic/Hospital
Primary Care Veterinarian*
Veterinarian's name Clinic/Hospital
Additional Veterinarian
Veterinarian's name Clinic/Hospital
Additional Veterinarian
Veterinarian's name Clinic/Hospital
Additional Veterinarian
Veterinarian's name Clinic/Hospital
Patient Information
Pet Name*
Name Goes By
Date of Birth
MM slash DD slash YYYY
Species
Breed
Weight in Pounds
Sex
- Male
- Female
- Neutered
- Spayed
Is Your Pet Microchipped
- Yes, please enter number below
- No
Microchip Manufacturer and Number
Do you have Pet Insurance
- Yes, please list below
- No
Pet Insurance Carrier
Reason for Evaluation (be as specific as possible)*
Onset / Duration of Problem*
Past Treatment(s) for this Condition and Response.
Diet and Amount Fed (please list specific brands and variety, formulation (dry/canned), measured amounts of all, as well as any treats regularly given)*
How is your pet's appetite
- Normal
- Increased
- Decreased
- My pet loves to eat
- My pet is picky
- My pet is not food motivated
Does your pet have any food allergies? (If yes, please list)
How is your pet's water intake?
- Normal
- Increased
- Decreased
- Frequent small sips
- Large amounts at one time
Your pet's urination is:
- Normal
- Increased
- Decreased
- Incontinent
- Straining/Vocalizing
The urine appears:
- Normal
- Clear
- Dark
- Bloody
- Large Volumes
- Small volumes
Your pet's stools are:
- Normal
- Increased
- Decreased
- Diarrhea
- Blood/mucus in stools
- Incontinent
- Excess Gas
Your pet's skin/feet/nails:
- Normal
- Dry skin with large flakes
- Dry skin with small flakes
- Brittle Nails
- Dry foot pads
- Itchy skin
When is your pet most itchy?
- Never
- Only sometimes
- During the day
- At night
- All the time
Please describe any coat changes or lesions you have noticed
Your pets respiration/breathing is:
- Normal
- Coughs
- Has had a change in breathing
Describe any changes in breathing
Had your pet's voice or noise that he/she makes changed at all? If so, please describe
Does this condition inhibit activities? If so, which activities and when?
Does your pet have problems with any of the following? (check all that apply)
- Slippery Surfaces
- Uneven Surfaces
- Mild inclines
- Mild declines
- Short walks
- Long walks
- Ascending stairs
- Descending stairs
- Posturing for urination
- Urinary accidents/dripping urine
- Posturing for defecation
- Fecal accidents/dropping stool
- Difficulty getting into/holding a sitting position
- Difficulty getting into a lying position
- Difficulty standing for any length of time
- Difficulty arising from sitting
- Difficulty arising from lying down
- Difficulty walking
- Limps during walking (indicate which limb below)
- Difficulty running
- Painful or lame following exercise
- Other (please enter below)
Limb(s) with lameness:
Other mobility issues not listed above:
When are the signs worst?
- First thing in the morning
- Late in the day
- During activity
- After activity
- After rest
- Same all the time
Activity level prior to injury/problem (indicate all that apply)
- Leash walk
- Leashed jog/run
- Off-leash park/free play
- Activity play (ball, Frisbee, etc)
- Competitive athlete (i.e. agility, obedience, field, hunting, protection, flyball, etc)
Does your pet seem painful? When? If yes. please grade on a scale of 1-10 (1=mild, 10=severe)
Do you see your pet stretch during the day?
- Yes
- No
Has their stretch changed? Please describe
Energy and Well-Being
How is your pet's energy level in general
- Normal
- Reduced
- Increased
When is your pet's energy level the highest?
- Morning
- Afternoon
- Night
- Consistent
When is your pet's attitude the best
- Morning
- Afternoon
- Evening
- Night
- Consistent
How would you describe your pet's personality?
- Outgoing
- Shy
- Aggressive
- Content
- Restless
- Crabby
- Depressed
Does your pet prefer
- To be cool
- To be hot
- No preferences
How is your pet's sleep schedule?
- Normal
- Decreased
- Increased
- Restless at night
- Has frequent dreaming/vocalization/runing in sleep
Please describe where you pet sleeps
Has your pet had any behavioral changes recently? If so, please describe
Have you noticed any irritability in your pet? If so, when and why?
Has your pet ever demonstrated any agressive behavior? If so, when and why?*
Current medications (please list all prescribed and over the counter medications including dosage and frequency given)*
Current dietary supplements and herbal therapies (please list all, including dosage and frequency)*
Other medical history (Ex: seizures, heart conditions, respiratory conditions, surgeries, etc)
Does your pet have any past history of cancer? If yes, what type, when diagnosed, how treated?
What specific goals are you seeking for your pet through rehabilitation therapy?
Are you able/willing to do prescribed exercises at home as part of your pet's rehabilitation therapy?
Home Environment (check all that apply)
- Short flight of stairs
- Long flight of stairs
- Primary carpet in home
- Primarily tile/hardwood/linoleum in home
- Jumps onto bed and/or sofa
- Sleeps on owner's bed
- Small Yard
- Large Yard
- More than 50% of time outdoors in yard each day
- Access to dog door during the day
- Free access to house at night
- Access to dog door at night
- Young children at home
- Other pets in home (list below)
Other animals at the house (list type and number)
Are there any other concerns that you have that you have not found a space to include above?

Office Hours

Monday Closed
Tuesday 1PM-8PM
Wednesday 9AM-6PM
Thursday 1PM-8PM
Friday 9AM-6PM
Saturday 11AM-5PM

Information

Email
info@K9RehabMI.com

Doctor's hours by
appointment only.

Phone

Phone
(734) 253-2722

Fax
(734) 253-2736

Location & Directions

Animal Rehabilitation Facility
8040 4th Street
Dexter, MI 48130

Driving Directions

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