Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Preferred Method of Contact

Phone
Text
Email

Pet's Name

Species

Canine
Feline

Age/DOB if Known

Breed

Check One

Neutered male
Spayed female
Male
Female

Microchipped

Yes
No

How did you hear about Colorado Springs Veterinary Surgery and Rehab Center rehabilitation?

Referral from my Veterinarian
Referral from my friend
Internet search
Other

Whom may we thank?

Which platform (Facebook, Google, etc)?

If other, please specify

What specific goals are you seeking for your pet through rehabilitation therapy?

Are you able/willing to perform prescribed exercised at home as part of your pet’s rehabilitation therapy?

Primary Complaint

Duration of Problem

Past treatments for this condition

Input/Output

Diet: list specific brand(s)/type canned/dry, amount fed, and all treats regularly fed

Appetite

Water Intake

Detail food allergies, if applicable

Urination

Urine Appears

Stool

Respiration/Breathing

Breathing

Normal
Coughing
Has had changes

Please describe changes

Has your pet’s “voice” or noises that they typically make changed? Describe changes:

Does the condition inhibit activities? If so, what specific activities and when:

Mobility

Does your pet have problems with any of the following? Check all that apply:

If other, please specify

When are signs the worst?

Activity level prior to injury

Does your pet seem painful? If so, please grade from 1 (mild) to 10 (severe) and when it is painful (after walks, upon rising, etc.)

Do you see your pet stretch during the day? Has their stretch changed? Please describe:

Energy & Well Being

Energy level in general

Normal
Increased
Decreased

When is energy level the highest?

When is pet's attitude the best?

Describe pet's personality

Does pet prefer

To be cool
To be warm
No preference

How is pet's sleep schedule?

Describe where your pet sleeps

Behavior

Has your pet shown behavioral changes recently? If so, describe

Have you noticed any irritability? If so, when and under what circumstances

Has your pet ever demonstrated aggressive behavior? If so, when and under what circumstances

Medical Information

Current medications – please list all prescribed and over-the-counter medications, including dosage and frequency (e.g. 100 mg carprofen ½ tablet twice per day):

Current dietary supplements & herbal therapies (please list all)

History of medical conditions (e.g. Seizures, heart conditions, respiratory conditions, surgeries, etc.)

Any past history of cancer? If so, what type, when diagnosed, method(s) of treatment

Check all that apply to your pet’s home environment

Describe other pets in the home

Authorizations

Make my pet a social media star! I authorize and grant Colorado Springs Veterinary Surgery and Rehab Center permission to take my pet’s photograph and use it on social media, e.g., Facebook and website. Choose one

Yes
No, thank you

Record release: at times, your pet’s records may be requested by boarding facilities, groomers, referrals, or other veterinary practices; do you give permission for Colorado Springs Veterinary Surgery and Rehab Center to transmit patient records?

Yes
No

Veterinarian/Practice Name

Veterinarian/Practice Phone Number

Veterinarian/Practice Email *

Permission to treat: I hereby authorize the veterinarian at Colorado Springs Veterinary Surgery and Rehab Center to examine, prescribe for, or treat the above-described pet. I assume responsibility for all charges incurred in the care of this animal. I understand charges are due at the time of service/discharge and that a deposit may be required for treatment. *

Clear Signature

Accepted payment methods:

Cash
Visa/MasterCard
American Express
Discover
Care Credit
Wells Fargo Health Advantage
Scratchpay

Rehab Assessment Form