New Patient Orthopedic History Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Owner's Phone Type * Cell Landline Email * Co-Owner Name First Name Last Name Co-Owner Address Address 1 Address 2 City State/Province Zip/Postal Code Country Co-Owner Phone (###) ### #### Co-Owner's Phone Type * Cell Landline Co-Owner Email Would you like the co-owner's info to be added to the account? * Yes No N/A Pet's Name Species Canine Feline Other Breed Color Date of Birth Sex Neutered Male Spayed Female Male Female Microchip/Tattoo Number Date of Most Recent Rabies Vaccination * Where was the Most Recent Rabies Vaccination Performed? * Family Veterinary Hospital * Family Veterinary Doctor Additional Veterinary Hospital/Specialist Additional Veterinary Doctor Do you have a Pet Insurance Policy? If no, then simply put N/A in the next two boxes Yes No If yes, what is the insurance company? If yes, what is the Policy Number? * How did you hear about us? * Family Veterinarian Internet Search Family/Friend Word of Mouth Other If you were referred by word of mouth, please provide their name so we can thank them! Orthopedic History Which leg hurts? * Check all that apply. To determine if left or right, stand behind your pet. Their right and left sides will be the same as your own. Right Front Leg Left front Leg Right Rear Leg Left Rear Leg Back/Spine is painful Does your pet limp? * Yes No If yes, please check all that apply. Limping is more noticeable after a rest Limping is more noticeable after activity Limp is present all the time Limping is periodic Does your pet have difficulty rising? * Yes No Sometimes Does your pet have difficulty or avoid walking on slippery (wood/tile/vinyl) floors? * Yes No Sometimes Does pain medication help your pet's symptoms? * Limping resolves Limping is less noticeable My pet is more active and energetic No change with pain medicaiton How long has your pet had this condition? Is your pet's condition getting worse? * Yes No Staying the Same Has your pet already had surgery for this condition? * Yes No Has there been any change in appetite? * Yes No Is your pet urinating normally? * Normal Urination Increased Urination Decreased Urination Have you observed any vomiting? * Yes No Have you observed any loose stools or diarrhea? * Yes No Is your pet losing or gaining weight? * Same Weight Gaining Weight Losing Weight Does your pet have a heart murmur or other heart condition? * Yes No Has your pet ever had a seizure? * Yes No If yes, what is the frequency of the seizures? Please list any seizure medications Please list any medications your pet is currently taking. * What brand of food does your pet eat? * How many times per day does your pet eat? * Once Twice Free Choice Does your pet have any other health conditions? If yes, please specify. Has your pet had any other major surgery? If yes, please specify. ** If you are filling out this form in advance of your appointment, please remember to do the following: 1. Please bring all of your pet's medications with you to the appointment. 2. Do not feed your pet at least 8 hours before your appointment in case we need to give you a sedative or perform an operation. 3. Please contact your family veterinarian to make sure they have sent your medical records and radiographs. WE LOOK FORWARD TO MEETING YOU!! Thank you!
