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Name

Pet’s Name

Phone number

Breed of pet

Pet age

Sex

M

F

Background

How long has your pet been suffering with his/her mobility problem?

Up to 6 months

6–12 months

12–24 months

24–36 months

more than 36 months

Has your dog been diagnosed as suffering from any other problems in addition to his/ her orthopedic disease?

No

Yes

If you can, please list any medications that your pet is currently receiving, stating when he/she received the last dose of each:

What medication is your dog currently taking, and when did he/she last receive a dose of each of these medications?