Name *
Name
Address *
Address
Phone (cell) *
Phone (cell)
Phone (other)
Phone (other)
Date of last physical exam
Date of last physical exam
Include any problems or concerns you are hoping to address through massage therapy (anxiety, pain, wellness, etc.).
List any previous surgeries with approx. date and reason
Include date, diagnosis, treatment and current symptoms
Include the name, purpose and dose for each item.
List any known allergies to medications or food.
Describe types of exercise, frequency and any challenges or recent changes in activity.
Mobility improves with:
Describe general demeanor and any recent changes in behavior or temperament.
Describe type of food (canned, raw, dry), amount and frequency. Include any treats and frequency.
Other health concerns
Please check all areas in which you have noticed recent symptoms or changes in habits.
Please list any other therapy the animal is currently receiving. (acupuncture, physical therapy, hydrotherapy)