Pet's name* is  Please Select eating/drinking normally eating/drinking abnormally not eating or drinking at all *  . He/she eats  brand/type of food*   
Do you feed table food?   Please Select We occasionally feed table food. We never feed table food. Yes, we often feed table food. *   


Has he/she experienced any of the following symptoms in the last 5 days?     vomiting   not eating   diarrhea   sneezing   coughing   my pet is not coughing/sneezing/vomiting/diarrhea and is eating well.*         

If you answered yes you any of the above symptoms, how long have these symptoms been going on?   Please Select Symptoms for a few days. Symptoms for a few weeks. Symptoms for a few months. These symptoms do not apply *           

Urine and bowel movement frequency and consistency is:  normal urine and bowel movements   abnormal urine and bowel movements   unsure what their urine and bowel movements are like*      

Are there any lumps/bumps/growths that need to be checked today?
Yes, please check lumps/bumps growths   No lumps/bumps/growths need to be checked today*   

Please mark all concerns that apply:
My pet is experiencing : 
Bad Breath   Limping       Open wound   Scratching Ears/Shaking head    Skin issues/rash/sores/infection   Difficulty getting up or laying down   Trouble walking or standingDrainage from eyes/nose  Rubbing squinting eyes   Discomfort while urinating/defecating   None of these concerns apply*                                                           


Is your pet taking any medications?
Yes, my pet is on medications   No*, my pet is not on any medications    
                          
Do you give Flea/Tick/Heartworm Preventatives?
Yes, we give monthly prevention   No*, we do not give monthly prevention
         
Do you need a refill of heartworm-intestinal parasite, flea and tick preventative medications?
Yes, I need to refill monthly prevention medication .   No refills needed at this time.   I decline monthly preventatives.*        

List all medications your pet is currently taking:   *

If vaccinations are due, please select the ones you'll be updating at this visit. Please select Decline if you Wish to decline this vaccine today. If your pet is up to date, no selection is required.
Rabies *Required by Law* 
Da2pp Distemper/Parvo   Decline Da2pp Distemper Parvo 
Leptospirosis  Decline Leptospirosis
Bordetella   Decline Bordetella   
Influenza  Decline Influenza   
Lyme   Decline Lyme*    

If you would like to learn more about these vaccines and why we feel they are important, please click here to read all about them.     https://veterinarypartner.vin.com/default.aspx?pid=19239&id=4951406

Please list any additional questions or concerns you have for the doctor so we can be sure to address them at this appointment.
questions or concerns   

Our standard of veterinary care is to do annual wellness blood work and fecal testing. Certain medications may require that your pet has blood work tested every 3 - 6 months. Please plan to bring a fresh fecal sample with you to your appointment if your pet is due for annual testing or is having stool concerns. If this is not possible, a sample may be collected at the time of the blood draw.
Thank you and see you soon!