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Welcome to Dells Vet
Please fill out the following questions to help us serve you today.
17
Questions
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1
Will you be leaving your dog here for their exam and treatment?
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This field is required.
Answer "yes" if this is a drop off appointment
YES
NO
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2
Your Name
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This field is required.
Don't worry, we'll ask your dog's name next
First Name
Last Name
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3
What is your dog's name?
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Fill in your dog's name that we are seeing today:
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4
Email
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This field is required.
We need your email to send you lab results, health reminders and health updates. We don't spam it!
example@example.com
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5
Phone Number
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This field is required.
What is the best number to reach you at during the day?
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6
Authorization of medical treatment
Be 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
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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
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quote
Created with Sketch.
Ok
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8
Tell us about your dog's diet
*
This field is required.
Use the boxes below to tell us what foods your dog loves
Fill in all the foods your dog likes (dry, canned, dental treats, people food, treats.) and brands if you know them.
Once a day meal feeding
Twice a day meal feeding
Three or more times a day
Food is always available
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 dog?
What does your dog like to hunt?
How many cups of food a day, total?
Yes
No
I'm not sure how much they are eating or drinking.
Yes
No
I'm not sure how much they are eating or drinking.
Are they eating and drinking normally?
No, thank you.
Yes, I have questions.
I only want to discuss this if medically necessary.
No, thank you.
Yes, I have questions.
I only want to discuss this if medically necessary.
Questions about the diet?
Yes
No
I don't know
Yes
No
I don't know
Is your dog on a grain free diet?
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9
Where does your dog hang out?
*
This field is required.
Tell us about your dog'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
Only goes out to potty
Boarding
Travels out of state
Camping or hunting
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10
Medications
*
This field is required.
Choose all of the medications that your dog is on
Heartworm preventative
Monthly Flea and tick preventative
Joint supplement
Over the counter pain meds
Herbal medication
Prescription medicine
I need a refill
not taking any medications
Other
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11
Almost done!
*
This field is required.
Check any of the boxes below that apply to your dog
I'm worried about my dog's breath and dental health
My dog isn't as active as they used to be or is acting lame
I have noticed a change in my dog's behavior
I'm worried about my dogs eyesight or hearing
My dog has a skin or ear infection
My dog is having accidents in the house
My dog has a lump
I have no health concerns today
Other
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12
Dental Questions
Tell us more about your pets teeth
Bad breath
Loose teeth
Broken or discolored teeth
Sore when they eat
Swelling around the face
Bad breath
Loose teeth
Broken or discolored teeth
Sore when they eat
Swelling around the face
Choose all of the following problems your pet has
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
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:
Never
Less than 1 year ago
1-2 years ago
Over 2 years ago
Never
Less than 1 year ago
1-2 years ago
Over 2 years ago
When was their last dental cleaning with x-rays
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13
Lameness Questions
Tell us more about your pet's lameness
Left front leg
Right front leg
Left rear leg
Right rear leg
Neck
Back
Stiff/slow in general
Left front leg
Right front leg
Left rear leg
Right rear leg
Neck
Back
Stiff/slow in general
Where are they sore?
All the time
When they wake up, then it gets better during the day
Only after exercise
At night
All the time
When they wake up, then it gets better during the day
Only after exercise
At night
When are they sore?
It waxes and wanes
Less than 1 week
1 week - 1 month
More than 1 month
It waxes and wanes
Less than 1 week
1 week - 1 month
More than 1 month
How long have they been sore?
Rest
Ice
Heat compress
Prescription meds
Over the counter meds
Nothing
Rest
Ice
Heat compress
Prescription meds
Over the counter meds
Nothing
What therapies have you tried at home?
Yes
No
A little
Yes
No
A little
Did anything help?
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14
Eye Questionnaire
Choose all the problems you notice with your pets eyes
Water or colored discharge from eyes
Red eyes / eye lids
Poor vision in bright light
Poor vision in dark light
Cataracts
Painful eye
Other
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15
Skin and Ear questionnaire
Tell us about your pets problems
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
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?
Year round
Spring
Summer
Fall
Winter
Year round
Spring
Summer
Fall
Winter
What seasons of the year do you see this?
Never gets over them
Weekly
Monthly
Every 3-6 months
Never gets over them
Weekly
Monthly
Every 3-6 months
How Frequently does your dog get infections?
No
Other dogs
Other Cats
People in the house
No
Other dogs
Other Cats
People in the house
Does anyone else have a skin infection?
Inside
Outside on cement only
Outside on mowed grass
Outside in tall grass
Swimming in a lake or river
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?
Monthly heartworm preventative
Monthly flea / tick preventive
Medicated bathes
Allergy meds
Antibiotics
Topical sprays
Fish oil supplements
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
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
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?
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16
Accidents in the house Questionnaire
Tell us what type of problem you are having
Formed
Soft, pudding like
Watery diarrhea
Blood in the stools
I haven't seen a stool in over 48 hours
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
No vomiting
Vomits
Vomits hours after they eat
Vomits partially digested food or feces
Vomits yellow bile liquid
Vomits blood or dark brown coffee grounds
No vomiting
Vomits
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
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
They are on medication:
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
They are on medication:
Is there anything they may have eaten to set this off? Choose all that apply
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
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 accidents in the house? Choose all that apply
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17
Lump Questions
Tell us more about your dog's lump:
Where are the lumps
Not sure
Less than a week
More than a week
Not sure
Less than a week
More than a week
How long has it been there?
It is rapidly growing
It is painful
It has discharge
I'm worried about cancer
I want it removed
It is rapidly growing
It is painful
It has discharge
I'm worried about cancer
I want it removed
Check all that apply to the lumps
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18
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