CLIENT HISTORY
Date: _________________
Last Name: _____________________________ First Name: __________________________
Patient Name: ______________________ Breed: ___________________________________
Sex: ______ Age: _______ Diagnosis: ___________________________________________
Date of Last Visit: ____/____/____
Wt.: ______kgs
Why is your pet being seen at our clinic today?
____________________________________________________________________________
How long has your pet had this problem?
____________________________________________________________________________
Was there an initial traumatic incident?
____________________________________________________________________________
Have you noticed any worsening or have there been improvements in your pet’s condition, since
you first noticed your pet’s injury?
_______________________________________________________________________________
_______________________________________________________________________________
Does your pet have a difficult time rising from a lying position?
_____________________________________________________________________________
Is your pet allowed on the furniture/bed? Is this difficult for them?
_____________________________________________________________________________
Does your pet become exhausted easily with exercise?
_____________________________________________________________________________
What kind of daily exercise does your pet receive?
_____________________________________________________________________________
Have you sought other treatment modalities in the past (heat/ice, acupuncture, massage, etc.)? Any
positive effect? ___________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
©2014 Copyright Canine Rehabilitation LLC, All Rights Reserved.
Client History Page 2
CURRENT MEDICATIONS & DOSAGES
Pharmaceutical Drugs
(QD = 1x daily, BID = 2x daily, TID = 3x daily, QID = 4x daily, EOD = Every other day)
Aspirin______ mg QD BID
Deramaxx ______ mg QD
Etogesic______ mg QD BID
Meloxicam ______ ml/mg QD
Previcox______ mg QD
Rimadyl______ mg QD BID
Zubrin______ mg QD BID
Prednisone ______ mg BID QD EOD
Amantadine______ mg QD
Amitriptyline______ mg QD BID
Gabapentin______ mg QD BID
Omeprazole ______ mg QD
Oxycodone ______ mg BID QID
Tramadol______ mg QD BID TID QID
Tylenol ______ mg QD BID
Nutraceutical Supplements
CanEva caps ______ g QD
Cosequin ______ tabs QD BID
Dasuquin ______ tabs QD BID
Duralactin ______ mg BID
Fatty Acids (Fish Oils______ QD BID
GastricCalm ______ tabs QD
Adequan: _______ml
Glucosamine/Chondroitin Sulfate ______ QD BID
Hyaflex ______ ml QD
Hyalun ______ ml QD
MSM______ QD BID
Welactin ______ tsp QD
1x week [ ] 2x weekly [ ] every other week [ ] once monthly [ ]
Other Medications not listed on this form
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
What results have you seen since last treatment?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Have you noticed any new or unusual problems since last treatment?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
©2014 Copyright Canine Rehabilitation LLC, All Rights Reserved.