AHI Cares - Pre-Visit Form

1
What is the date of your appointment?* This field is required.
Date
Year
Month
Day
2
Who is your pet's appointment with?* This field is required.
Dr. Scott Murray
Dr. Debbie Dennis
Dr. Megan Barnhizer
Dr. Kelly Schwaner
Dr. Scott Brown
Dr. Jennifer Drake Johnston
Dr. Christine Hadley
Dr. Andrea Carlson
Dr. Christi Hanzel
Veterinary Nurse
I am not sure
3
Client Details* This field is required.
First Name
Last Name
Email
Cell Phone Number
Your Pet's Name
4
Please select your pet's reason for visiting us* This field is required.
Wellness Visit/Vaccines/Preventative Care
Medical Concern
Follow-up
Anesthetic Procedure
Other
5
If other, please specify
6
Is your pet experiencing any of the following (check as many as apply)* This field is required.
Lethargy (Sluggish)
Weight Loss or Trouble Eating
Vomiting or Diarrhea
Respiratory Concerns
Lameness or Difficulty Moving Around
Behavior Concerns
Not Experiencing Any Known Medical Concerns
Other
7
If Other, please specify
8
Please describe further any other concerns you would like the doctor to know about. If no concerns, type n/c.* This field is required.
9
Does your pet typically like or dislike his/her visit with us?* This field is required.
Loves coming in!
Hesitant but ok.
Hates the car ride more.
Experiences mild signs of anxiety.
Experiences moderate signs of anxiety.
Typically needs sedation.
10
Is your pet currently taking any medication? Please also include any Supplements, Heartworm/Flea/Tick medications.* This field is required.
Yes
No
11
If so, please list the medications he/she is taking. Include dosing information (how much/how often).
12
When was the last dose of Heartworm and Flea/Tick Prevention given?
Yes
No
Do you require any refills? We recommend that you double check before your appointment.
13
What BRAND of food does your pet eat? Please be specific.
Dry food only
Canned food only
Both canned and dry food
What type of food does your pet eat?
How many times a day do you feed your pet?
How much does your pet eat at each feeding? Please be specific (cups, cans, etc.)
14
What additional treats, snacks, or human food does your pet receive. Please be specific and indicate frequency. * This field is required.
15
Has your pet's environment changed at all? This includes the addition of new pets, boarding/grooming/training, travel, etc.
Yes
No
16
If yes, how?
17
What is your pet's primary environment?* This field is required.
Strictly indoor
Strictly outdoor
Spends time both indoors and outdoors
18
To make your pet's visit more positive, we offer food rewards such as treats, canned food or cheese, and peanut butter. Please select from the following* This field is required.
No concerns, go ahead!
I will bring my pet's favorite treats along
My pet has food allergies
My pet is coming in for gastrointestinal issues
Avoid Peanut Butter d/t allergy in household
Should be Empty: