Appointment date and time: (required)
Are you (the owner) or anyone living in your home quarantined because of COVID-19 or showing related symptoms? (required) Yes No Primary Reason for Appointment (please be as detailed as possible) (required) What brand of Heartworm Prevention is your pet on? When was the last dose of Heartworm and Flea/Tick prevention given? Please list all medications and supplements (including over the counter) that your pet is taking: Do you need any medication refills today? If so, please list the name of the medication and amount needed. Is your pet experiencing any of the following (check as many as apply): Weight loss or Trouble Eating Vomiting Diarrhea Coughing Sneezing Limping Trouble moving around Behavior concerns Please select your pet's energy level: Normal Increased Decreased What brand of food do you feed your pet? How much food and how often do you feed your pet? What additional treats, snacks, or human food does your pet receive? Please be specific and indicate frequency. Patient's appetite Normal Increased Decreased Water intake/drinking Normal Increased Decreased Patient's urination habits Normal Straining Decreased Blood present Increased Dark Cloudy Strong/Foul odor Please list all of the places where your pet goes: Fenced in yard Yard that isn't fenced Farm Hiking, Camping or Swimming Boarding Grooming Doggy DayCare Indoor cat Outdoor cat Indoor/outdoor cat Hunting Leash walks Visit friends and family Any previous patient history that we should be aware of? Would you like to ask the veterinarian anything or add any additional information? What are your pet's favorite treats? Has your pet ever been prescribed medications to help with a veterinary visit in the past? If so, what medications were they and what kind of result did you experience? How would you describe your pet's reaction to going to the veterinary hospital? Eager and Excited Subdued Reluctant Somewhere in between Check any situations listed below that your pet has shown avoidance or dislike of in the past. You can add additional comments at the end of this form. Getting in their carrier or the car Entering the Veterinary Hospital Other pets and/or people passing by while in the reception/check-in Waiting with other people and animals in the waiting area Being approached by veterinary staff Getting on the scale for a weight Hearing the doorbell, overhead intercom, or phones ringing Sounds coming from the back areas of the practice Going into the exam room Being put up on the table for examination Having direct eye contact with the technician and/or veterinarian Loud voices during examination Having a rectal temperature taken The use of instruments such as the stethoscope or otoscope (to look into the ears) Being taken out of the exam room for procedures How and where does your pet travel in the car? (carrier, seatbelt, loose, ect.) How does your pet behave in the car? Does your pet show any signs of nausea with car travel, such s drooling or vomiting? How would you describe your pet around other animals and people? Does your pet have any sensitive areas that he does not like to have touched or examined by your or others? Are there any procedures your pet has not liked having performed at the veterinary hospital in the past or that seemed difficult for you or the staff to do? (Nail trims, temperature, ear exam, blood draw, ect.) Does your pet like to play with toys? If so what kinds? Anything else you would like us to know?