General or Annual Physical Exam

General or Annual Physical Exam

Please give us these answers to save time in your appointment! If multiple pets are coming, please complete a form for each pet.
Pet Name*

First NameLast Name
Your email address*
example@example.com
Do you prefer to receive reminders via email or regular US mail?
Has your pet ever had a vaccine reaction? (Swelling, hives, difficulty breathing, vomiting)
Please tell us what your pet eats. Include brand name of food, amount fed, how often fed, AND include treats!*
What percentage of time does your pet spend outdoors?

Do these circumstances describe the life of your pet? Select Yes or No*

Rows	Yes	No	N/A
Other pets at home
Children in the home
Elderly in the home
Immune-compromised individuals in the home
Human allergy to fish/peanuts
Exposure to wildlife
Goes to a boarding facility
Goes to the groomer
Goes to the Dog Park
Goes hiking/to the lake/to the mountains
Smokers in the home

Would you like to discuss any of the following health concerns at your appointment? Please select Yes or No:*

Rows	Yes	No
Vomiting
Diarrhea
Coughing
Sneezing
Behavior changes or issues
Scratching or chewing
Abnormal discharge
New lumps, bumps, or rashes
Lameness

Please describe the following aspects of your pets behavior:*

Rows	Normal	Increased	Decreased
Energy
Appetite
Water intake
Urination
Stools

Does your pet travel? If so, please tell us where*
Regarding heartworm and intestinal parasite prevention, is your pet on this....*
How many months of heartworm/intestinal parasite prevention should we get for you today? blank

An important part of your pets care is establishing THEIR normal lab values through annual wellness testing so that we might catch problems earlier. Did you wish to provide this level of care? We are happy to discuss costs with you! (We have also negotiated a bundled price with our lab to make this more affordable.)*

Rows	Yes	No
General Wellness blood profile (Complete Blood Count , organ function, thyroid)
Heartworm Test (if due)
Fecal Test for Intestinal Parasites
Urinanalysis

Last question!! Please list ALL supplements and medications your pet receives. Include name, dose strength(i.e., mg, tablet), and how often it is given. While we have this in our records, sometimes administration changes - so we ask.)*
Thanks so much for your efforts in completing this form! Please let us know if there are any other concerns you would like to discuss with the Doctor while you are here:*
Our entire team is dedicated to giving our best to you and your beloved pets, which includes treating you with courtesy and respect.

In return, I expect every client to do the same for our team.

From this point forward, all forms of disruptive behavior are prohibited in our office. Incidents of disruption, verbal aggression in person, via email, or on the phone, and/or threats of violence will result in your exclusion from our practice.

Examples of prohibited behaviors include but are not limited to:

Threats, Physical aggression, Verbal harassments, including abusive language, cursing, shouting, and/or sexual comments, Demeaning behavior and comments, Failure to follow facility policies and procedures

Thank you for being kind and helping everyone be safe.
Should be Empty: