Puppy History Chart 2.0

1
Will you be leaving your puppy here for their exam and treatment?* This field is required.Answer "yes" if this is a drop off appointment
YESNO
2
Your Name* This field is required.Don't worry, we'll ask your puppy's name next
First Name
Last Name
3
What is your puppy's name?* This field is required.Fill in your puppy's name that we are seeing today:
4
Email* This field is required.We need your email to send you lb results, health reminders and health updates. We don't spam it!
example@example.com
5
Phone Number* This field is required.What is the best number to reach you at during the day?
6
Authorization of medical treatmentBe advised that you are leaving your pet here today because a doctor is not available for immediate examination. If you feel that your pet's condition is deteriorating or that they may die, we recommend taking them immediately to the Veterinary Emergency Hospital In Sioux Falls and not leaving them here. When the doctor has a chance to examine your pet, the medical team will call the number you have left on this submission form and discuss diagnostics, treatment options and cost. If your patient's condition becomes life threatening at any point do you want:
CPR
Do Not Resuscitate
7
What health concerns do you have today?Type in all of your concerns, and we will make sure we address them today!
Huge
Large
Normal
Small
Ok
Ok
8
Tell us about your puppy's diet* This field is required.Use the boxes below to tell us what foods your puppy loves
Fill in all the foods your puppy likes (dry, canned, dental treats, people food, treats.) and brands if you know them.
Please Select
Please Select
Once a day meal feeding
Twice a day meal feeding
Three or more times a day
Food is always available
How often do you feed your puppy?
Tell us everything they hunt!
How many cups of food a day (total) do they eat ?
Please Select
Please Select
Yes
No
I'm not sure how much they are eating or drinking.
Eating and drinking normally?
Please Select
Please Select
No, thank you.
Yes, I have questions.
I only want to discuss this if medically necessary.
Questions about the diet?
Please Select
Please Select
Yes
No
I'm not sure
Is the diet grain free?
9
Where does your puppy hang out?* This field is required.Tell us about your puppy's favorite places to stay, choose all that are appropriate
Groomer
Dog Parks
Outside on a leash
Outside in a fenced yard
Outside off leash
Outside using underground fence
Only goes out to potty
Boarding
Travels out of state
Camping or hunting
Puppy classes
Sleeps in a crate
Sleeps with someone in bed
Other
10
Medications* This field is required.Choose all of the medications that your puppy is on
None
Heartworm preventative
Monthly Flea and tick preventative
Joint supplement
Over the counter vitamins or supplements
Medication from the breeder
Prescription medicine
I need a refill
I have questions about medications
Other
11
Almost done!* This field is required.Check any of the boxes below that apply to your puppy
I'm worried about my puppy's dental health or their chewing behavior
I have questions about their behavior
I noticed they are limping
My puppy has a skin or ear infection
My puppy is having accidents in the house
I have no health concerns today
Other
12
Behavior QuestionsChoose all the areas that you have concerns about for your puppy today
Walking on a leash.
Crate / kennel training.
House training
Barking
Chewing on things
Playing too rough
Jumping on people
Learning to "sit"
Other
13
Dental QuestionsTell us more about your puppy's teeth
Please Select
They look great, I just have questions about keeping them healthy!
Bad breath
Loose teeth
Broken or discolored teeth
The jaws don't line up straight
Choose all of the following things your puppy has:
Please Select
I don't have a dental routine
I give them dental treats
I brush their teeth at home or put on a sealant
I have their teeth professionally cleaned
Tell us about your dental routine for your pet:
Please Select
Nothing, they really don't chew.
Puppy toys like rubber Kongs, rubber bones, rope toys.
Natural items like sticks, rocks, bones
Shoes, furniture, pieces of my house.
People, other pets
What things do they like to chew on?
Please Select
Never has any of these problems
Snores
Sneezes
Coughs when excited
Has problems breathing through his nose
Any times they sneeze, snore, or seem to have problems breathing through the nose?
14
Lameness QuestionsTell us more about your pet's lameness
Please Select
Left front leg
Right front leg
Left rear leg
Right rear leg
Neck
Back
Where are they sore?
Please Select
All the time
When they wake up, then it gets better during the day
Only after exercise
At night
When are they sore?
Please Select
Please Select
It waxes and wanes
Less than 1 week
1 week - 1 month
More than 1 month
How long have they been sore?
Please Select
Rest
Ice
Heat compress
Prescription meds
Over the counter meds
Nothing
What therapies have you tried at home?
Please Select
Please Select
Yes
No
A little
Did anything help?
15
Skin and Ear questionnaireTell us about your pets problems
Please Select
Red skin
Red bumps on skin
White scales on the hair
Scratching/itching
rubbing face
Rubbing bottom on the floor
Hair loss
Licking feet
Licking other parts of the body
Ear infection
Bad odor
Infections around the mouth or eyes
Broken nails
Weird looking foot pads
Vomiting or diarrhea
Flatulence (gassy)
Frequent, large soft bowel movements
opt3
What symptoms are you seeing at home?
Please Select
Year round
Spring
Summer
Fall
Winter
What seasons of the year do you see this?
Please Select
Please Select
Never gets over them
Weekly
Monthly
Every 3-6 months
How Frequently does your dog get infections?
Please Select
No
Other dogs
Other Cats
People in the house
Does anyone else have a skin infection?
Please Select
Inside
Outside on cement only
Outside on mowed grass
Outside in tall grass
Swimming in a lake or river
Where does your dog spend their time?
Please Select
Monthly heartworm preventative
Monthly flea / tick preventive
Medicated bathes
Allergy meds
Antibiotics
Topical sprays
Fish oil supplements
Choose all the meds that your pet is on
Please Select
Stored in the original bag
Stored in a plastic container
Food and water in a metal bowl
Food and water in a ceramic bowl
Food and water in a plastic bowl
How is the food stored and fed?
16
Accidents in the house QuestionnaireTell us what type of problem you are having
Please Select
Formed
Soft, pudding like
Watery diarrhea
Blood in the stools
I haven't seen a stool in over 48 hours
How are the stools? Check all that apply
Please Select
No vomiting
Vomits <30 minutes after they eat
Vomits hours after they eat
Vomits partially digested food or feces
Vomits yellow bile liquid
Vomits blood or dark brown coffee grounds
Is there any vomiting? Choose all that apply
Please Select
No, they only eat dog food.
Human food
Garbage
Lawn or cleaning chemicals
Foreign body like a toy
String from a blanket or toy
I don't watch them outside, so I'm not sure.
They are on medication:
Is there anything they may have eaten to set this off?
Please Select
No
No, but my dog needs to go out to the bathroom all the time
Yes they urinate in the house
I have seen blood in the urine
Other
Are there any urine spots in the house?
Please Select
Please Select
Yes, and the accidents happen in the crate
Yes, but the accidents happen outside the crate in the house
No, I do not use a crate
Is your puppy in a kennel or crate?
Should be Empty: