First Visit Form - Chicago Animal Rehab

First Visit Form

Please complete the FIRST VISIT FORM (below) prior to arriving at CARE.





PET OWNER INFORMATION

First and Last Name (required):

Spouse or Partner’s First and Last Name:

ADDRESS INFORMATION

Street Address (required):

City (required):

State (required):

Zip (required):

CONTACT INFORMATION

Your Email (required):

Your Phone Number (required):

Your Work Phone:

Your Cell Phone:

OTHER INFORMATION

Whom may we thank for your visit?:

PRIMARY VETERINARIAN INFORMATION

Please provide contact information of your pet’s primary veterinarian so we may keep them posted about treatments provided to your pet by CARE:

Veterinarian’s Name:

Animal Hospital:

Veterinarian’s Phone Number:

Veterinarian’s E-mail Address:

PET INFORMATION

Please complete the General Health information below:

Pet’s Name:

Species:

Breed:

Date of Birth (approx):

Sex:

Neutered or Spayed:

GENERAL PET CONDITIONS

What is the primary reason for your visit?

Please note changes to any of the following – Food or Water Consumption; Urination; Defecation; Weight; Vision; Hearing; Activity Level; and/or Sleeping Pattern:

HISTORY OF SURGERIES

Beisdes spaying or neutering, has your pet had any surgeries? If so, please explain what type and when:

LEGS and JOINTS

Has there been any lameness?

If “yes”, which leg(s) are affected? (select all that apply)

Was there any known trauma that occurred prior to you seeing lameness?

Has the patient demonstrated any difficulty on rising, climbing stairs or descending stairs? (select all that apply)

Do these signs worsen or improve with exercise?

FOOD and DIET INFORMATION

Please list your pet’s diet, amount and frequency:

MEDICATIONS and SUPPLEMENTS

Please list the names, doses and length of time each medication and supplement has been given:

OTHER OBSERVATIONS

Are there any other observations that you would like to note at this time?

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