CANINE FITNESS ZONE

Vet Screen Form

Canine Fitness Zone Veterinary Release for Strength/Condition/Stretch Class Dog Name:________________________________________________Age__________________  Owner Name: __________________________________________________________________ Address:_______________________________________________________________________ Phone:_________________________________________________________________________ E-mail:_________________________________________________________________________

Medical History Questions:   1.       Is your dog currently taking any medications?  If so, please list all medications, including dose, frequency, and how long he/she has been on the particular medication.    2.       Has your dog had any previous injuries or trauma?  If so, please list the date(s) and explain the nature of the injury, including treatment and recovery.  3.       Does your dog have a history of respiratory or cardiovascular disease?  (This includes heart murmurs, syncope, chronic cough, and dyspnea).  Is your dog currently on any medication for such diseases?  4.       Has your dog had any history of episodes of recent or recurring lameness or gait abnormalities?  Please describe and list any medications/treatments prescribed.

Physical Exam, including orthopedic exam and gait analysis:  1.       Complete physical exam – including EENT, cardiovascular auscultation, respiratory auscultation, abdominal palpation, TPR, and weight.  2.       Orthopedic exam/gait analysis:       -Observation of the gait at walk and trot to evaluate for obvious lameness.  Particular attention to obvious limping or signs of possible lameness, including:  shortened strides, dragging of toenails, “toeing-in” or “toeing-out,” hypermetria, “bunny-hopping,” stumbling, ataxia, criss-crossing of the rear legs, or asymmetry of gait or stance.         -Joint Manipulation to screen for signs of pain or instability.  Should include rotation, extension, and hyperextension to screen for signs of pain or crepitus.  Joints to be examined:                             ·          Carpus               ·          Elbow               ·          Shoulder               ·          Stifle (includes screen for patellar luxation and cranial drawer motion or severe crepitus)               ·          Coxofemoral joint

Is this dog cleared to take Strength & Conditioning?          YES                 NO Exercise Precautions:     Is this dog cleared to take Stretch Class?                            YES                 NO  Exercise Precautions:   Veterinarian Signature/Date:  _________________________________________________________ © South Mesa Vet Clinic, 2009. All rights reserved. Used by CFZ with Permission.