Catskill Patient history form

Patient Exam History Form

Existing clients and patients
Date
Your name *

First Name Last Name
Pet's name *
Phone Number *

Area Code Phone Number
Email
example@example.com
COVID-19 Health Survey:

Please answer these questions honestly so we can prepare proper levels of PPE to keep our team safe. An answer of YES does not exclude you from treatment. Please answer YES or NO to each of the following questions: *

YES

Do you have a fever or above normal temperature?

Have you experienced shortness of breathe or had trouble breathing?

Do you have a dry cough?

Do you have a runny nose?

Have you recently lost or had a reduction in your sense of smell?

Do you have a sore throat?

Have you been in contact with someone who has tested positive for COVID-19?

Have you tested for COVID-19?

Have you been tested for COVID-19 and are awaiting results?

Have you traveled outside the United States by air or cruise ship in the past 14 days?

Have you traveled within the United States, by air, bus or train within the past 14 days?

Explain any YES answers in the box below:
Let's start with their mouth:
Do you have a concern for your pet's mouth or teeth?

Yes No
What are your concerns (check all that apply)?

Odor coming from mouth Gums are red and irritated Tartar and/or discoloration on teeth Lumps and bumps around mouth Concerns about loose or broken teeth Having trouble chewing or drinking
Has your pet experienced this before?

It is a new problem. Yes and it is not as bad as it was before. Yes and it is about the same as it was before. Yes and it is worse that it was before. My pet has had frequent episodes of the same or similar problems.
How long has this been going on?
Additional notes:
And their eyes:
Do you have concern about your pet's eyes?

Yes No
I have concerns about (check all that apply):

Are red and irritated Have a gunky discharge Are "weepy" Are cloudy. Vision-my pet does not seem to see well. Frequently scratching or rubbing them
Has your pet experienced this before?

It is a new problem. Yes and it is not as bad as it was before. Yes and it is about the same as it was before. Yes and it is worse that it was before. My pet has had frequent episodes of the same or similar problems.
Which eye?

Right Left Both
How long has this been going on?
How much time outside?
Any exposure to chemicals/irritants:
Have you observed:

Sneezing Coughing Nasal Discharge Change in appetite Vomiting or diarrhea Itching or scratching on other parts of body
Ears:
Do you have a concern for ears?

Yes No
My pet's ears (check all that apply):

have some gunk and debris once in awhile. always seem to have some debris. sometimes have a yellow or brown discharge. seem red or swollen on the inside. seem swollen or irritated on the outside. seem itchy. S/he scratches them frequently. are of concern. My dog does not seem to hearing as well as s/he used to.
Which ear?

Right Left Both
Has your pet experienced this before?

It is a new problem. Yes and it is not as bad as it was before. Yes and it is about the same as it was before. Yes and it is worse that it was before. My pet has had frequent episodes of the same or similar problems.
How long has this been going on with the ears and has pet had previous issues?
Is there:

Head shaking Head tilt Odor from the ear(s)
Have you observed:

Sneezing Coughing Nasal Discharge Change in appetite Vomiting or diarrhea Itching or scratching on other parts of body Changes in diet Changes in swimming or bathing behavior
Additional notes-are you using any cleaners or medications at this time?:
Respiratory:
Do you have concerns about your pet's breathing?

Yes No
My pet (check all that apply)

seems to cough, sneeze, or gag more that s/he used to. seems to pant more. has changed his or her vocalizations. seems to get out of breath easily. seems to be more anxious, and I feel like his or her heart is beating faster at times. has intense coughing or gagging has intense panting at times
Has your pet experienced this before?

It is a new problem. Yes and it is not as bad as it was before. Yes and it is about the same as it was before. Yes and it is worse that it was before. My pet has had frequent episodes of the same or similar problems.
How long has this been going on?
How often is your pet displaying problems (check all that apply)?

Cough or sneezes once or twice daily Coughs or sneezes multiple times daily More frequent in the day More frequent at night Worsens after exercise or movement Frequent panting Increased abdominal effort with breathing Fainting episodes
Have you seen changes in activity level?

Less active than normal Activity level is the same More active than normal Appears lethargic Appears agitated
Environment:

My dog goes to a groomer or doggie day care My dog visits other households with pets or dog parks I foster pets and/or volunteer at a rescue or shelter There are other pets in the household with respiratory symptoms. We have COVID-19 exposure in our household.
Additional notes:
Skin and Body:
Do you have concerns about your pet's skin?

Yes No
My pet is:

scratching licking chewing/biting
My pet's coat and body (check all that apply)

is dull and not as soft as it used to be. is dry and my pet scratches frequently. seems to have an odor, and I see some crusty skin. has some hair loss. has open sores that do not heal. has some lumps and bumps. has patches of hardened or thickened skin. Has hot spots Has a rash
Has your pet experienced this before?

It is a new problem. Yes and it is not as bad as it was before. Yes and it is about the same as it was before. Yes and it is worse that it was before. My pet has had frequent episodes of the same or similar problems.
How long has this been going on?
Environmental changes:

My pet goes outside. My pet has been exposed to potential chemical irritants. There are other pets in the household with skin symptoms. My pet has had a change in diet.
What medications or treatments have you used?

regular baths medicated baths OTC sprays/ointments OTC or natural flea/tick products Prescription flea/tick products Prescription oral medications Foods or supplements such as fish oil
Mobility and movement:
Do you have concerns about your pet's walking and play?

Yes No
My pet (check all that apply)

seems awkward sometimes and limps once in awhile. is playing less than s/he used to, and having trouble moving. is slowing down and does not seem as interested in play. is stiff and has difficulty with stairs and climbing. seems to be painful sometimes when moving around. has an acute injury and is not walking on/toe touching one limb
Has your pet experienced this before?

It is a new problem. Yes and it is not as bad as it was before. Yes and it is about the same as it was before. Yes and it is worse that it was before. My pet has had frequent episodes of the same or similar problems.
What is most affected?

Right front leg Left front leg Both front legs Right rear leg Left rear leg Both rear legs Hips and entire back area Overall mobility concerns
How long has this been going on?
Additional information:
GI system/weight/appetite
Do you have concerns about your pet's eating and elimination behavior?

Yes No
My pet (check all that apply)

Is gaining weight eating the same amount of food. has gained weight and is eating more. has gained weight but s/he is actually eating less. has lost weight but is still eating like s/he used to. has lost weight and is eating less. seems to be hungry all the time. seems to be thirsty all the time. is drinking more water than s/he used to. seems to have trouble eating his/her normal food. Does not seem to be that interested in food/refusing
For primary nutrition, my pet eats (check all that apply):

a homemade diet. a raw food diet. a high quality commercial dry food. a high quality commercial wet food. a prescription diet. a commercial name brand dry food. a commercial name brand wet food. a store brand dry food. a store brand wet food. only people food.
My pet (check all that apply)

is having trouble controlling his/her bladder is making messes in the house seems to be urinating more frequently. seems to be defecating more frequently. has strong smelling urine. has unusually strong smelling stools. has frequent loose stools or diahrrea. seems to get constipated. seems to get nausea frequently. seems to vomit frequently. seems to have a sensitive stomach. frequently gets into stuff s/he should not eat.
Has your pet experienced this before?

It is a new problem. Yes and it is not as bad as it was before. Yes and it is about the same as it was before. Yes and it is worse that it was before. My pet has had frequent episodes of the same or similar problems.
How long has this been going on?
Have there been any recent changes in your household environment that could be impacting your pet?
Additional information and concerns:
Behavior:
Do you have concerns about your pet's behavior?

Yes No
My pet (check all that apply)

continues to struggle with behavioral problems (please let us know what these are) is showing increased anxiety is showing increased aggression sometimes seems confused is not as responsive to us as s/he used to be is lethargic and sometimes acts depressed
Has your pet experienced this before?

It is a new problem. Yes and it is not as bad as it was before. Yes and it is about the same as it was before. Yes and it is worse that it was before. My pet has had frequent episodes of the same or similar problems.
How long has this been going on?
Have there been any recent changes in your household environment that could be impacting your pet?
Additional information and concerns:
My primary concern today is:
Are there any other questions that you would like us to address at your visit?
Thank you so much for completing this survey. We appreciate your deep knowledge of your pet, and this helps us partner more effectively with you to develop the best plan to address your concerns and meet your pet's and your family's needs.
When you submit this form, you acknowledge that your answers you provided are true and accurate to the best of your knowledge:
Should be Empty:

Patient Exam History Form

COVID-19 Health Survey:

Let's start with their mouth:

And their eyes:

Ears:

Respiratory:

Skin and Body:

Mobility and movement:

GI system/weight/appetite

Behavior: