Patient Pre-Checkin

1

Owner's Name

First Name

Last Name

2

Pet's Name

3

In order to have the best experience possible, please make note of the following:

1. Plan to arrive 10-15 minutes prior to your appointment for check-in.
2. If your pet is experiencing diarrhea or G/I symptoms, bring in a stool sample, if possible.
3. Due to limited space, please refrain from using retractable leashes in our lobby. We are happy to provide a slip leash for your use in the clinic.
4. Friendly reminder, not all pets play well with others. Please keep a close eye on your pet and do not allow them to socialize in the lobby. We would hate for your pet to pick-up any germs or get bit by another dog.
5. There will be a $30 no-show/cancellation fee if you do not cancel or reschedule at least 24 hours before your scheduled appointment. Please see email for current appointment policies.
6. A 3.00% customer service charge is applied to all credit card sales. To avoid paying the service fee, please plan to pay with cash or check.
7. To ensure accurate medical records, we may use an AI note-taking system during your pet’s exam. This could involve audio recording, used solely for documentation purposes and kept securely.

If you have any questions, please ask a team member!

4

I have read and agree to the appointment policies.

5

Chief complaint or reason for visit?

6

Is your pet inside, outside or both? If pet goes outside what is the environment like? (Ex: leash walked, fenced in yard, free roam, tie out/runner, dog lot, etc.)

7

Does your pet travel outside of your home? If so, how often & where? (Hiking, camping, dog parks, out of the state, pet stores/stores in general, grooming, etc.)

8

Is your pet around any other animals? If so, what other pets?

9

Describe your pet’s eating habits:

Normal

Decreased

Increased

Other

10

Please explain if increased or decreased:

11

Has anything changed at the time of the food intake? Diet, weather, visitor at home, new baby, new pet, new home, vacation, prescriptions, over the counter supplements, etc.

12

What kind of food does your pet eat?Brand and flavor

13

What kind of snacks or treats does your pet eat?

14

How often is your pet fed & how much?

15

Does your pet get table food? If so, what & how often?

16

Describe your pet’s drinking habits

Normal

Decreased

Increased

Other

17

Please explain if increased or decreased:

18

Do they share a water bowl with other pets?

YESNO

19

How often do you change the water in one day?

20

Has anything changed at the time of the water intake? Diet, weather, visitor at home, new baby, new pet, new home, vacation, prescriptions, over the counter supplements, etc.

21

Is your pet on any heartworm prevention?* This field is required.

YESNO

22

Heartworm Medication Brand and date last given?

23

Is your pet on any flea/tick prevention?* This field is required.

YESNO

24

Flea/Tick Prevention Brand and date last given?

25

Does your pet take any over the counter medications or supplements?* This field is required.Please include dosage and frequency.

26

Is your pet on any prescription medications?* This field is required.Please include dosage and frequency.

27

Does your pet have any medical conditions (Previous or Current)?

28

Has your pet been experiencing any diarrhea?

YESNO

29

When did it start?

30

How often? Frequency?

31

Is there any blood or mucous in the stool? If so, was the blood dark red or bright red?

32

Describe the consistency (cow patty, soft served ice cream, liquid, etc.):

33

What is the volume of the stool?

34

Could they have eaten something inappropriate? If so, what & when?

35

Have you administered any medications? If so, what & when?

36

Has there been any environmental changes at the time of when the diarrhea was noticed? Diet, weather, visitor at home, new baby, new pet, new home, vacation, prescriptions, over the counter supplements, etc.

37

Has your pet been experiencing any vomiting?

YESNO

38

When did it start?

39

How soon before or after eating does the vomiting occur?

40

Is the food digested or undigested?

Digested

Undigested

41

Are there any foreign objects in the vomit? If so, what?

42

What is the consistency of the vomit? Ex: food, water, bile, color

43

How frequently are they vomiting?

44

Could they have eaten something inappropriate? If so, what & when?

45

Have you administered any medications? If so, what & when?

46

Has there been any environmental changes at the time of when the vomiting was noticed?Diet, weather, visitor at home, new baby, new pet, new home, vacation, prescriptions, over the counter supplements, etc.

47

Is your pet experiencing any coughing?

YESNO

48

When did it start?

49

How often do they cough?

50

Describe the cough.Dry/hacking, productive, high pitch wheeze, etc.

51

Did your pet lose consciousness before, during, or after the cough? If so, for how long? Did you noticed your pet’s mucous membrane color (color of the gums)? White/pink/red/purple

52

Does the cough seem to happen more at a certain times of the day or after a certain activity?

53

Is your pet experiencing any sneezing?

YESNO

54

When did it start?

55

Is it constant or intermittent?

56

Is there any nasal discharge? If so, clear/mucous/greenish yellow/bloody:

57

Does your pet spend any time outside unattended?

YESNO

58

Is your pet urinating normally?

YESNO

59

Has the urine production increased or decreased?

Increased

Decreased

Other

60

When did this start?

61

Is this change daily?

YESNO

62

When was the last time they urinated?

63

Is there any straining to urinate?

YESNO

64

Do they ever posture & not produce any urine?

YESNO

65

Is the odor stronger than normal?

YESNO

66

What is the color of the urine?(Clear, yellow, bloody, etc.)

67

Has anything changed at the time of when urination habits changed? Diet, weather, visitor at home, new baby, new pet, new home, vacation, prescriptions, over the counter supplements, etc.

68

What is your pet’s exercise tolerance like?

Normal/Stable

Progressed

Regressed

Other

69

Please explain the change:

70

When did you first notice the change?

71

Describe your pet’s general attitude:

72

Are you happy with their attitude?

YESNO

73

Have you seen any behavioral changes?

YESNO

74

Please select behavioral problem(s) your pet is exhibiting:Select all that apply.

Eliminating in the house

No longer sleeping through the night/Changes in sleep patterns

Need to eliminate more often

No longer coming when called

Seems depressed

More active

Signs of aggression

75

Please describe signs of aggression in detail:

76

Has anything changed at the time of the behavior change?Diet, weather, visitor at home, new baby, new pet, new home, vacation, prescriptions, over the counter supplements, etc.

77

Have you noticed any lumps/bumps on your pet?Both new or pre-existing.

YESNO

78

Are they new?

YESNO

79

Have they been looked at before?

YESNO

80

Do they bother the pet?

YESNO

81

Have they changed in shape or size?

82

Have you noticed any limping or favoring of limbs?

YESNO

83

Which leg?

Front Right

Front Left

Back Right

Back Left

84

Is it constant or intermittent?

85

Are they weight bearing or holding completely up?

86

Has there been an injury? If so, when did the injury occur & describe:

87

Have you noticed any issues with your pet’s ears?

YESNO

88

Which ear is affected?

Right

Left

Both

89

When did it start?

90

Is your pet scratching or shaking their head? Is it keeping you or your pet up at night?

91

Does your pet have a history of ear infections? If so, how often do they occur? Does it seem to be seasonal?

92

Have you given or applied any medication? If so what & when?

93

Have you noticed any issues with your pet’s skin?

YESNO

94

When did it start?

95

Is your pet licking, biting, scratching themselves? Is it keeping you or your pet up at night?

96

Does your pet have a history of skin infections? If so, how often do they occur? Do they seem to be seasonal?

97

Have you given or applied any medications? Have you bathed with any shampoo or conditioner? If so, what & when?

98

Have you noticed any changes with your pet’s eyes?

YESNO

99

Which eye is affected?

Right

Left

Both

100

Is your pet rubbing or squinting their eyes?

101

Has there been an injury to the eye? If so, when did the injury occur & describe the nature of the injury?

102

Is there any discharge coming from the eye(s)?Please describe. (clear, yellow, green)

103

Any special instructions or questions?

104

Printed name of Responsible Party:

105

Signature

Clear

106

Phone NumberPlease provide the phone number you will be available at during the appointment time.

Area Code

Phone Number