Recheck Questionnaire

Recheck Questionnaire

Thank you for scheduling your Recheck Appointment. Please, fill out this form and submit 3 days prior to your Recheck appointment.
Your Name *

First Name Last Name
Secondary Guardian's Name

First Name Last Name
Patient Name *
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Medication/Supplement #1
Strength
Dose
Frequency
This medication is:
Date Started

Month Day Year
Date
Is your pet experiencing side effects? If so, please describe.
Medication/Supplement #2
Strength
Dose
Frequency
This medication is:
Date Started

Month Day Year
Date
Is your pet experiencing side effects? If so, please describe.
Medication/Supplement #3
Strength
Dose
Frequency
This medication is:
Date Started

Month Day Year
Date
Is your pet experiencing side effects? If so, please describe.
Medication/Supplement #4
Strength
Dose
Frequency
This medication is:
Date Started

Month Day Year
Date
Is your pet experiencing side effects? If so, please describe.
Medication/Supplement #5
Strength
Dose
Frequency
This medication is:
Date Started

Month Day Year
Date
Is your pet experiencing side effects? If so, please describe.
Any other medications or supplements your pet is currently on - including name, strength, dose, frequency of administration and if any behavioral effects:
Has your pet had any visits to a veterinary clinic since our last appointment? *

Yes No
If so, describe and include which clinic they visited:
For each behavior problem your pet originally presented for, please update us on the status of how things are going:
Behavior Problem #1
Percentage improvement
Changes you have noticed
Behavior Problem #2
Percentage improvement
Changes you have noticed
Behavior Problem #3
Percentage improvement
Changes you have noticed
Have you submitted any videos since the last time we saw you?

Yes No
Have any new behaviors emerged since we last met? If so, describe:
What seems to be working well?
What seems to not be working well?
Are there any therapies that were recommended that you have been unable to implement?
What are your current goals?
Is there anything else you'd like to share?
Recording Disclaimer: Some virtual appointments are recorded automatically, some are not pending automated settings, storage space, etc. These recordings are utilized for our own reference later regarding tracking the case, training, and preserving valuable behavioral information and progress. These recordings are stored confidentially in our medical record system and we utilize them in line with our educational and media release form you signed on intake. At any time if you wish not to have a session recorded then please do not hesitate to let us know and we can turn the recording off.
Should be Empty:

Recheck Questionnaire

For each behavior problem your pet originally presented for, please update us on the status of how things are going: