Caring Hands Vet - Appointment Questions

1

Reason for today's Visit* This field is required.

2

Which would you prefer for you pet’s exam today?* This field is required.

Curbside

In-person (up to 2 masked individuals)

3

Client & Patient Information* This field is required.

First Name

Last Name

Email

Pet's Name

4

Best number to reach you during today’s appointment* This field is required.

5

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

Yes

No

6

Please list all medications (medication name, dosage, frequency)* This field is required.

7

Is it OK for us to give your pet treats while visiting us?* This field is required.

YESNO

8

Sometimes we may give peanut butter as a treat. Does anyone have peanut allergies in your household?* This field is required.

YESNO

9

Have you noticed any change in any of the following?* This field is required.Please select all that apply

Appetite

Activity Level

Urination

Defecation

Water Intake

None

10

When did you first notice the change in your pet's appetite?* This field is required.

11

When did you first notice the change in your pet's activity level?* This field is required.

12

When did you first notice the change in your pet's unration?* This field is required.Please describe this change in frequency, amount, color, etc.

When did you notice this change?

Please describe

13

When did you first notice the change if your pet's defecation?* This field is required.Please describe this change in frequency, consistency, etc.

When did you notice this change?

Please describe

14

When did you first notice the change in your pet's water intake?* This field is required.

16

If your pet is vomiting* This field is required.

When did the vomiting begin?

17

Do you know if anything your pet may have eaten that would cause GI upset?* This field is required.

18

Please describe the frequency & consistency / color* This field is required.

19

If your pet has diarrhea* This field is required.

When did the diarrhea begin?

20

Do you know of anything your pet may have eaten that would cause GI upset?* This field is required.

21

Please describe the frequency & consistency / color* This field is required.

22

If your pet is coughing* This field is required.

When did the coughing begin?

23

Does it seem to be associated with any particular activity?* This field is required.

24

If your pet is sneezing* This field is required.

When did the sneezing begin?

Please describe the frequency

25

Please describe your pet's lumps or bumps* This field is required.

26

Please describe your pet's skin irritation or itching* This field is required.

27

Is your pet on Heartworm or Flea & Tick prevention?* This field is required.Please select all that apply

Heartworm Prevention

Flea & Tick Prevention

None

28

Heartworm Prevention* This field is required.

What is the Brand name?

29

What is the date you last gave this medication to your pet?* This field is required.

30

Flea & Tick Prevention* This field is required.

What is the Brand name?

31

What is the date you last gave this medication to your pet?

32

Pet's Diet* This field is required.

What is the name/brand of food your pet eats? Wet or dry?

How much do you feed your pet?

How often do you feed your pet?

33

COVID-19 Screening* This field is required.Are you or anyone in your household currently diagnosed with, being tested for, or exhibiting any symptoms of COVID-19?

Yes

No

34

Have we seen your pet before?* This field is required.

Yes

No

35

If we have not seen your pet before, where can we call to get their previous medical history?* This field is required.