Skip to content
Hospital:
(919) 303-3456
• Pet Resort & Spa:
(919) 323-8877
PET MEDS DELIVERY
Rx REFILL
VET REFERRAL
FORMS
Search for:
Hospital (919) 303-3456
Resort & Spa (919) 323-8877
Emergency Care
Patient Portal
Rx Refill Requests
PET MEDS DELIVERY
VET REFERRAL
Contact
Search for:
Search for:
About
Veterinarians
Jodi Reed, DVM
Charles Livaudais, DVM
Molly Shelton, DVM
Mikaela Archambeault, DVM
Corisa Cheston, DVM
Kelsi Ferris, DVM
Katelyn McSpadden, DVM
Jazlyn Sharp, DVM
David Schur, DVM
Jordan Woodruff, DVM
Staff
Ambassadors
Hours & Policies
Reviews
Hospital
Preventive & Wellness
Diagnostics & Treatment
Medication & Pharmacy
Common Pet Poisons Guide
Dental Care (COHAT)
Rehabilitative Therapy
Pet Insurance
Hospital Reviews
Resort & Spa
Pet Grooming & Spa
Dog Boarding
Dog Daycare
Cat Boarding
Resort Vaccination Requirements
Harmony Pet Resort & Spa Reviews
Emergency
Resources
Blog
Newsletters
Harmony Animal Rescue Clinic
Cat Life Stages & Care
Dog Life Stages & Care
Videos
If You Have Lost Your Pet
Products
Common Pet Poisons Guide
Pet Insurance
Recommendations & Referrals
Contact
Patient Portal – Appointments
Forms
Client Records Request
Employment Opportunities
About
Veterinarians
Jodi Reed, DVM
Charles Livaudais, DVM
Molly Shelton, DVM
Mikaela Archambeault, DVM
Corisa Cheston, DVM
Kelsi Ferris, DVM
Katelyn McSpadden, DVM
Jazlyn Sharp, DVM
David Schur, DVM
Jordan Woodruff, DVM
Staff
Ambassadors
Hours & Policies
Reviews
Hospital
Preventive & Wellness
Diagnostics & Treatment
Medication & Pharmacy
Common Pet Poisons Guide
Dental Care (COHAT)
Rehabilitative Therapy
Pet Insurance
Hospital Reviews
Resort & Spa
Pet Grooming & Spa
Dog Boarding
Dog Daycare
Cat Boarding
Resort Vaccination Requirements
Harmony Pet Resort & Spa Reviews
Emergency
Resources
Blog
Newsletters
Harmony Animal Rescue Clinic
Cat Life Stages & Care
Dog Life Stages & Care
Videos
If You Have Lost Your Pet
Products
Common Pet Poisons Guide
Pet Insurance
Recommendations & Referrals
Contact
Patient Portal – Appointments
Forms
Client Records Request
Employment Opportunities
History Questions for Initial Rehabilitation Consult Form
Home
/
History Questions for Initial Rehabilitation Consult Form
Welcome to Harmony Animal Hospital!
History Questions for Initial Rehabilitation Consult
Step
1
of
3
33%
Owner Name:
First
Last
Date of Initial Consult:
MM slash DD slash YYYY
Address:
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Phone:
Email Address:
*
Enter Email
Confirm Email
Patient:
Pet's name
Species (Cat or Dog)
Patient Birth Date:
MM slash DD slash YYYY
Patient Info:
Breed
Age
Weight
Color
Patient Sex:
Female
Spayed Female
Male
Neutered Male
Primary Veterinarian:
First
Last
Primary Veterinarian Phone:
Is your veterinarian aware you are seeking rehabilitation evaluation/treatment for your pet?
How did you hear about us?
Is your pet up to date on vaccines? Bordatella and up to date fecal exams are required for Underwater treadmill therapy.
Yes
No
When did your pet last:
Eat
Drink
Urinate
Defecate
List all diets fed currently including treats, and in the past, to your best recollection:
Dry, Canned, Moist, Raw
Brand (Please state full name)
Flavor/Protein source
Cups/Cans per meal
Meals per day
Example : Dry, Purina Beyond, Lamb and rice, 1, 2
Doers pet have any food allergies? If yes, please list.
What medication(s) or supplements is your pet taking, and when was last administration?
Medication/Supplement
Dose
Frequency
What is your primary reason(s) for seeking treatment?
When did this problem start?
Did you witness the incident/accident?
Has your pet experienced this problem in the past? If yes, how was it treated?
At what specific times of day do the signs seem the worst?
What previous treatments have been tried? Was there a response?
Is your pet limping? Which limb? Is there anything that aggravates the limp?
Is the problem improved or worsened with exercise? What seems to aggravate the problem?
Does your pet seem in pain?
Does your pet stretch? Has this changed?
Any noticeable gait changes? i.e. limping, clumsiness, difficulty turning or weaker on slick surfaces, crossing over?
Does your pet have trouble rising from seated or laying down position?
Does your pet prefer to lay to one side?
Is stair climbing or descending a problem?
What type of flooring must your pet negotiate daily? Does your pet find any of these surfaces difficult to navigate?
How is your pet’s appetite recently? If not normal, is it more ravenous or finicky?
Are his/her stools loose or dry?
Any vomiting?
How is his/her overall thirst? Does he/she drink small amounts or large amounts at a time?
Describe the urine color, frequency and odor change.
Is there any leaking of urine?
Any problems posturing to urinate or defecate?
Any concerns with skin/feet/nails? Any open wounds, lumps, flaking, itching etc?
Any problems falling asleep or staying asleep?
Have you seen evidence of dreaming?
How is his/her energy and stamina?
Is s/he startled by loud noises or sudden movements?
Does s/he prefer cool/hard or warm/soft places to rest?
Is s/he restless or fidgety?
Does his/her voice seem louder/coarser or weaker/thinner?
Any breathing changes?
Please describe his/her overall emotional state.
Please describe your pet’s daily exercises. Include information about going up/down stairs.
Please list any current or previous medical conditions, even if we will not be directly addressing them during our sessions.
Does your pet have a history of cancer? If so, what, where and has it been treated?
Please describe your pet’s personality. Does your pet have any behavioral problems or idiosyncrasies?
What activities do you do with you pet?
Are you willing to perform at-home rehabilitation exercises that may be prescribed for your pet?
What are your specific long and short term goals for your pet with rehabilitation therapy?
Please write any additional information you feel is important in your pet’s care.
Please prove you are human by selecting the
Star
.
Email
This field is for validation purposes and should be left unchanged.
Go to Top
