Lameness History (Dog) Form

Your Email*

Patient*

Client*

1. Which limb is involved*:

Right FrontLeft FrontRight HindLeft Hind

2. Character of the Lameness:

20a. Duration of the lameness*:

DaysWeeksMonths

2b. Onset Type*:

Acute (sudden) onsetGradual onset

2c. Was there an event (trauma or other) that started the lameness? *:

YesNo

If yes, please briefly explain:

3. Overall the lameness has been*:

Mild (barely noticeable)ModerateSevere (only slightly touching the leg down when walking)Non-weight bearing (not using the leg at all)

4. Since the lameness started, it has*:

ImprovedStayed the sameProgressively worsenedIntermittent

5. Mark all that apply regarding the lameness:

Worse following periods of increased activitySymptoms are consistent throughout the dayWorse first thing in the morningHas difficulty jumping or going up stepsWorse at the end of the dayHas difficulty going down stepsWorse when first getting up from a lying position

6. Prior to injury/lameness, my dog was*:

Highly active/athlete/working dogModerately active (walks, hikes, swimming, play at parks, etc.)Minimally active

7. Please list all medications (including amounts, timing) your dog is currently taking:

Medication 1:

ImprovementNo ChangeUnsure

Medication 2:

ImprovementNo ChangeUnsure

Medication 3:

ImprovementNo ChangeUnsure

8. Other information that might be helpful regarding my pet's condition: