Intake Assessment Form

General Information - Dog

Dog's Name

Dog's Breed

Dog's Gender

Age / DOB

Spay / Neutered?

Yes

General Information - Human

First Name

Last Name

Address

City

State

Zip Code

Phone/Mobile

Emergency Contact

Text Input

Phone/Mobile

Medical Information

Please provide the names and numbers of all the medical professionals your pet sees.

Medical Information

Medical Providers Name	Medical Providers Phone

Were you referred by a healthcare provider?

Yes

Referring Provider

Providers Phone

Reason for Referral

Health History Past/Present

Has your dog had a recent injury?

Yes

Describe the Injury

Has your dog had a recent surgery?

Yes

Performed by Whom:	Surgery Date

In the surgery site closed?

Yes

Has your Vet consented to water therapy for your dog?

Yes

Has your dog had any surgeries previously? (In addition to the one listed above)

Yes

Please describe:	Surgery Date

Does your dog have any issues with bowel/bladder control?

Yes

Is there anything more you'd like us to know?

Any known food allergies?

Yes

Describe the Allergies

Has your dog ever bitten anyone (including you)?

Yes

Describe the Injury

Please describe your vaccination schedule.

Please list your methods, if any, of flea control used.

Please describe your dog’s home environment. Where do they spend their day/night time?

Is your dog around children or other pets? Please describe.

What level of training has your dog received? Basic, advanced, specialized?

How are you hoping your dog will benefit from warm water therapy?

What is your Dog’s relationship to water Like?

Does your dog like to swim after toys?

Yes

Does your dog enjoy being held or massaged?

Yes

Please describe any emotional/behavioral components for me to be aware of so I can honor your dog’s boundaries and help them be as comfortable and confident as possible during our session.

Is there any other information we need? Do you have questions, or concerns?

programs

Intake Form

General Information - Dog

General Information - Human

Emergency Contact

Medical Information

Health History Past/Present