Canine Intake Form - CS Hydro Physio Ltd

Canine Intake Form For Owners

We would greatly appreciate it if you could take 15 minutes to complete this form. Please provide as much detail as possible about your dog below before their initial consult at CS Hydro Physio. This information will assist our team in tailoring a treatment plan specific to your dog’s needs and allow for more time during your consultation for introduction to hydrotherapy and physiotherapy equipment and techniques.

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Owner Name *

First

Last

Pet Details

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Pet Name *

Breed *

Colour *

Pet Age *

Date of Birth (DOB)

Gender & Neutering Status *

Weight (Kg) *

Medical History

Please let us know why you are bringing your dog to CS Hydro Physio in detail, as well as any other medical history your dog has had from an ear infection to lameness and surgeries.

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What Is The Reason You Are Bringing Your Dog To CS Hydro-Physio? *

Please describe in detail the reason you are bring your dog to hydro-physio. Include medical condition(s) (i.e. hip dysplasia, arthritis, muscle loss etc..), as well as time frames, surgeries undergone ect...

Does Your Dog Have Any Of The Following Conditions or Concerns? *

N/A
Tumours and/or Undiagnosed Lumps
Open Wounds or Stiches
Chronic Ear Infections
Respiratory Issues
Photosensitivity, Epilepsy or Seizures
Heart Conditions
Other

Does Your Dog Have Any Skin Or Food Allergies, Intolerances Or Concerns? *

Yes
No, none that I am aware of

Please Give Details on Allergies and Intolerances *

Is Your Dog On Any Medication? *

Please Give Details About The Medication(s) Your Dog is On?

Please detail type, frequency and dosage.

Does Your Dog Have Any Other Medical History Or Health Concerns Asides From The One You Have Come To See Us For? *

Please inform us of any other veterinary visits your dog has had throughout their life, including ear infections, stomach problems, allergies, lameness, etc. This information is crucial for assessing your dog's overall health. If possible, provide approximate dates or ages for these occurrences.

Has Your Dog Previously Received Hydrotherapy or Physiotherapy Treatment At Another Clinic? *

We may like to request previous treatment notes if your dog has seen a different therapist.

Supporting Documents

Click or drag files to this area to upload. You can upload up to 10 files.

Please attach any documents you have received from vets, previous therapists or anyone else you feel relevant.

Early Life

Please provide us with information about your dog's early life. The more details the merrier. This information assists us in building a comprehensive understanding of your dog's overall health, potential causes of any health concerns observed, or underlying conditions they may have. *If you have a rescue dog, some of the questions in this section may not apply to you.

Have You Had Your Dog Since A Puppy? *

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What Age Was Your Dog When You First Got Them? *

If your unsure as your dogs is a rescue please state that and make a rough estimate

How Did Your Dog Settle In When You First Got Them? *

Did they settle in well? Any memorable concerns?

Was Your Dog A Healthy Puppy? *

Did your dog suffer with any sickness, diarrhoea or other illness as a puppy. If yes please detail, if unknown then please move on.

What Exercise Did You Do With Your Dog As A Puppy? *

Please detail to the best of your memory the exercises you did with your dog as a puppy. Include information such as the age you started walking them, the duration (time) of walks, the rate at which you increased walking duration, when you introduced off-lead activities, toy throwing etc...

Can You Give Us Any Information On Your Dogs Health Or Exercises Levels Prior To You Owing Them?

Exercise Levels

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Please Tell Us A Bit About Your Dogs Exercise Levels Prior To Injury Or Concern *

What has your dog previously achieved? How many walks a day? How long for? And how far? How much on and off lead did they do? Did your dog do much in the way of ball throwing or playing with toys? Does your dog usually take part in any sports or activities (i.e. agility, gun dogs, sent work)

Please Tell Us A Bit About Your Dogs Current Exercise Levels *

What exercise is your dog currently doing? Has it changed or been reduced? Have you been given instructions by the vet regarding rest, walking, and progression?

What Is Your Ideal Post Treatment Exercise Goal For Your Dog? *

Ideally, what level of exercise would you like your dog to return to?

Diet & Behaviour

This information is to help us prepare for meeting you and your dog in the most positive way for them

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Please Tell Us Abit About Your Dogs Diet? *

What type (wet, dry, raw) and brand of food is your dog on? How many meals do they eat a day? Do you weigh out their feed?

Is Your Dog Generally Food Motivated? *

Do they eat their dinner quickly or pick at it? Do they like treats? Will they eat when anxious?

Does Your Dog Take Any Supplements? *

Please Give Details of Supplements *

Is Your Dog Confident In Water? *

Yes
No
Uncertain

If your dog is anxious around water, we ensure a conscious approach to introducing hydrotherapy equipment that matches your dog's pace and learning.

Does Your Dog Have Any Behavioural Concerns? *

No
Anxious Meeting Other Dogs
Anxious Meeting New People
Anxious In New Environments
Anxious At The Vets
Anxious/Uncomfortable Being Touched
History Of Biting
Other

Tick as many as relevant

Please Give Further Details If Necessary

Have You Noticed Any Recent Changes In Your Dogs Behaviour? *

Has your dogs behaviour changed recently? Are they less active? sleeping more? Are they struggling with crate rest and full of energy? Have they become more grumpy towards humans or other dogs recently comparted to have they were previously?

Home Environment

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What Type of Premises Does Your Dog Live In? *

If You Have Stairs At Home, Is Your Dog Allowed Up Them?

Yes, Freely
Yes, Only When Supervised
No
I don't have stairs

If you have any further comments on this please leave in the comment box at the end of this form.

What Types Of Floor Do You Have At Home? *

Carpet
Tile, Stone & Marble
Wood
Laminate, Vinyl & Linoleum
Epoxy
Other

Please select as many a relevant. If you have any further comments on this please leave in the comment box at the end of this form.

Has Your Dog Been Prescribed A Period Of Crate Rest Or Restricted Room Rest? *

For How long Have You Been Prescribed These Restrictions? *

Is Your Dog Allowed To Jump On And Off Of The Sofa & Beds At Home *

Yes, Freely
Yes, Only When Supervised
No, Never
No, But They Were Previously

If you have any further comments on this please leave in the comment box at the end of this form.

Have You Noticed Any Changes In How Your Dog Moves About The House? *

Are they slipping on the floor? Are they moving more slowly and cautiously? Have they stopped, or started to struggle, with jumping up onto the sofa or going upstairs?

Please Describe Changes In How Your Dog Moves About The House? *

Does Your Dog Have Access To Outdoor Spaces At Home? *

No Access To Outside Space
Small-Moderate Grass Garden
Large Grass Garden
Patio
Stones
Steps
Other

Please select as many a relevant. If you have any further comments on this please leave in the comment box at the end of this form.

Would You Be Interested In A Home Visit And Assessment From One Of Our Team To Help Identify Any Risk Factors For Injury/Re-Injury And Discuss A Home Management Action Plan?

Yes
No
Uncertain
I have already had/booked a home visit

If this is something you are possibly interested in it can be discussed further in your WhatsApp group or during your initial consultation.

Further Comments

Please write down any additional information...

Data Agreement *

I agree and understand that both my personal data and my dog's health information will be stored in a GDPR-compliant manner. This information will be used to help tailor my dog's treatment plan, monitor their progress, and improve their care. I understand that no information will be shared with any third parties.