Patient Intake Form: Examination

1
Owner Name:* This field is required.
2
Patient Name:* This field is required.
3
Cell Phone Number (where you can be reached during your appointment):
4
Has your address recently changed?* This field is required.
YESNO
5
Please Provide Us with Your Current Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
What is the best CELL phone number to reach you TODAY to discuss your pet's care?* This field is required.
Area Code
Phone Number
7
Email
example@example.com
8
Make/Model/Color of the Vehicle You are Driving Today:* This field is required.
9
What problem is your pet experiencing?* This field is required.
10
When did the problem start?* This field is required.
11
Is the problem the same, better, or worse?* This field is required.
12
Has a similar problem happened in the past? If so, when?* This field is required.
13
What is the pet's current diet (including treats)? Please specify brand, if known.* This field is required.
14
How often is your pet fed?* This field is required.
Once Daily
Twice Daily
Free Choice (Food available at all times)
15
Have you noticed any changes in your pet's appetite?* This field is required.
Increase
Decrease
No Change
16
What human food has your pet recently enjoyed?* This field is required.
17
Have you noticed any weight changes in your pet?* This field is required.
Increase
Decrease
No Change
18
Any changes in water consumption/thirst?* This field is required.
Increase
Decrease
No Change
19
Any increase in urination or accidents in the home?* This field is required.
Increase
Decrease
No Change
20
Any change in bowel movements?* This field is required.
Increase (Diarrhea)
Decrease (Constipation)
Normal / No Change
Unsure
21
What most accurately represents your pet's lifestyle:* This field is required.
Inside exclusively (uses litter box or potty pads for eliminations)
Outside exclusively
Inside and Outside
22
If your pet has access to the outdoors, is it:* This field is required.
Outside supervised on a leash
Outside unsupervised - in a fenced area
Outside unsupervised - free roaming without fence
Pet never leaves our home
23
Date of most recent vaccinations:* This field is required.
Use best estimate if exact date is unknown
24
Date of most recent heartworm test:* This field is required.
Use best estimate if exact date is unknown.
25
Date of most recent intestinal de-worming treatment:* This field is required.
Use best estimate if exact date is unknown.
26
Date of most recent labwork (CBC, Chemistry, etc):* This field is required.
Use best estimate if exact date is unknown.
27
Is your pet receiving monthly flea and tick prevention?* This field is required.
No
Yes
28
When was your last dose of flea and tick prevention given?* This field is required.
29
What brand of flea and tick medication are you using?* This field is required.
30
Is your pet receiving monthly heartworm prevention?* This field is required.
No
Yes
31
When was the last dose of heartworm medication administered?* This field is required.
32
What brand of heartworm medication are you using?* This field is required.
33
Are you interested in learning about the once-a-year heartworm preventative injection for dogs (Proheart 12)?* This field is required.Only available for dogs over 1 year of age.
Yes
No
My dog is already using this
34
Is your pet on any prescription medications? If so, what?* This field is required.
35
Has your pet recently finished a heat cycle? If so, when was her last heat?
36
Is your pet receiving any over-the-counter supplements (vitamins, joint support, CBD, essential oils, etc)?* This field is required.
37
Does your pet have any known behavior problems or aggression issues (biting, separation anxiety, etc) that we should be aware of prior to exam?* This field is required.
38
Does your pet have any known allergies or reactions to medications or vaccines?* This field is required.
39
Any other important medical history?
40
Additional Notes:
Should be Empty: