Consultation Questionnaire

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1. Your Information

Your First Name

Your Surname

Pet's Name

Age (Years/Months)

Species

Breed

Sex

Weight (kg)

How long have you had your pet?

Daily Diet

Appetite Change?

Altered Thirst?

Weight Change?

Previous Health Problems?

Surgical History?

What option BEST describes the current problem?

Describe the problem in your own words

How has it changed over time? Waxing/waning?

When did it begin?

Since onset, has it:

Limbs Affected?

Is limb held up?

Is limb dragged?

Currently Walking?

Yes No

Unsteady/Ataxic Gait?

Yes No

Current Treatments / Medications

Include injections, tablets, supplements. If none, write NO.

Video Submission

Short video clips of your pet walking are extremely useful. You can upload these via our Dropbox portal after submitting this form.

Video has been uploaded Video will be uploaded soon No video will be submitted

Additional Information / Comments