"*" indicates required fields Created*Client*PET INFORMATIONPet Name*Below you will find questions regarding the upcoming care for your pet. Basic history allows us to help streamline your pet's visit with us. Please fill out the required fields, and if your pet is experiencing any of the non-required fields please answer those questions as well.1. Have you noticed any issues/problems with your pet?2. What supplements, OTC medications, and/or prescription medications does your pet receive?3. Do you give heartworm prevention every month all year round or only during "warm" months? Every month, all year round Seasonally, during the warm months My pet does not receive heartworm prevention 4. Do you give flea/tick prevention all year round or only during warm months?5. When did your pet receive their last dosage of heartworm/flea/tick prevention? Within the last 30 days Within the last 3 months I'm not sure 6. What medication(s), monthly preventative(s), or prescription food do you need refilled today?7. Have you seen any fleas or ticks on your pet or any parasites in your pet's stool? Yes No 8. What is your pet's outdoors environment like? Wooded areas, hiking Standing water, lakes, streams Grass, neighborhood, urban Farm, rural, working dog (Please select all that apply)9. Does your pet go to any of the following? Boarding or Doggy Daycare Grooming Dog Parks Pet Stores Other (interacting with friends/family members dogs, etc) (Please select all that apply)10. What type of food do you feed your pet? What is your feeding routine? (amount offered, how many times daily)?11. Is your pet eating and drinking normal amounts? If not, what changes have you noticed?12. Have you noticed any changes in your pet's urination and defecation habits (frequency of urination or defecation, diarrhea or excessively hard stool, etc.)? No Yes I’m not sure 13. Has your pet had any vomiting, regurgitation or diarrhea? No Yes, occasionally and I'm not worried about it Yes, frequently and I want to talk to my nurse/doctor more about this 14. Have you noticed any lumps or bumps on your pet? No Yes and it/they are the same as during the last vet visit Yes and it/they have changed; I want to talk to my doctor/nurse about this 15. Has your pet been coughing or sneezing more than normal? No, no abnormal coughing nor sneezing Yes, coughing and sneezing more than normal Yes, coughing morethan normal Yes, sneezing more than normal 16. Is your pet scratching or chewing at themselves or doing any excessive head shaking? No, none of these Yes, scratching more than normal Yes, chewing/licking more than normal Yes, head shaking more than normal (Please select all that apply)17. We recommend yearly blood and fecal testing for your pet. Do you authorize this labwork? Yes, please do all recommended blood and fecal testing for my pet I'm not sure, I need more information from my nurse/doctor before making a decision 18. Does your pet need any additional services while with us today? Nail trim Anal gland expression Other. Please let your nurse or assistant know Other*Date* MM slash DD slash YYYY Consent* I have read and understand the statements and agree to all terms therein.Please note: Your privacy is important to us. All information received in all forms and through other communications is subject to our Patient Privacy. All payments are due at the time of services rendered.Enter the code below:
