St. Francis Animal Hospital - Pre-Examination History

Pre-Examination History Form

We require this form prior to all wellness exams and medical exams. This form is not required prior to acupuncture appointments or technician appointments.
Pronouns
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a number where we can reach you during your pet's exam.
Today's Date*

MonthDayYear
Appointment Date*

MonthDayYear
Which doctor is your pet scheduled to see?*
Have you or anyone in your family had known exposure to a person that has tested positive for COVID within the past 14 days?*
Beginning Monday, January 3rd, we returned to curbside service. This means that clients may not accompany their pets into the clinic except for end-of-life care (quality of life consultations or euthanasia). Do you have any concerns about remaining curbside?*

NoYes (please explain)
You may accompany your pet into the clinic for their exam, or you may remain in your vehicle if you would prefer. There are no longer any limits to the number of clients that may enter the clinic for exams. Would you like to come into the clinic or remain curbside for {petsName}'s visit?

I would like to come into the clinic.I would like to remain in my vehicle.I'm not sure yet- I will decide at the time of my pet's visit.
Please note that you must wear a mask at all times while you are inside St. Francis. Staff members will also be masked at all times. Thank you for helping to keep us safe and healthy!
Patient Information
Pet's Name*
Species*

DogCatRabbitFerretGuinea PigRatHamsterMouseGerbilHedgehogSugar GliderChickenDuckOther
Breed*
Age*
What is the reason for {petsName}'s visit?*

Annual/Wellness ExamMedical ConcernOther (please describe)
Fecal Samples
We recommend checking a fecal (poop) sample to screen for intestinal parasites once yearly in all dogs and cats, as well as whenever your pet has developed vomiting or diarrhea. Even indoor pets can pick up parasites, and some intestinal parasites can be spread to humans- especially small children or immunocompromised individuals. Please plan to bring a fecal sample to your pet's visit if they are due for their annual fecal test, or if they are experiencing GI upset.

Tips for a collecting an accurate fecal sample:
- Aim to bring us at least 5 grams of stool
  - This is about one teaspoon, or the size of about two marbles
- No frozen samples, please!
  - Freezing damages parasite eggs and makes them difficult to identify
- Samples should be no more than 24 hours old
  - If the stool is hard or crumbly, it is too dry for testing
  - Stools that have been outside on grass for several hours often get contaminated with fly larva or other types of parasites; fresher is better!
For more information about intestinal parasites, click here.

For owners of other species (i.e. rabbits, ferrets, chickens), fecal testing is not done routinely but may be recommended if your pet is having diarrhea. If you aren't sure if the veterinarian will want a sample, we recommend bringing one with just in case!
What are your concerns about {petsName}?*
Current diet*
Please include brand and how much food is offered per day
Current medications*
Please include preventative medications such a Heartgard Plus and supplements such as fish oils.
What preventative medications is your pet currently taking? Choose all that apply.*

Heartgard PlusNexgardFrontline GoldRevolution PlusNoneOther
Do you need refills of any preventative medications (i.e. heartworm or flea/tick prevention)?*

YesNo
Available Rebates
We have several instant rebates available for preventative medications in 2022:

If you purchase 12 Heartgard Plus AND 12 Nexgard or Frontline Gold: $60 rebate

If you purchase 12 Heartgard Plus AND 6 Nexgard or Frontline Gold: $35 rebate

If you purchase 6 Heartgard Plus AND 6 Nexgard or Frontline Gold: $25 rebate

If you purchase 12 Heartgard Plus: $15 rebate

If you purchase 12 Nexgard: $35 rebate

If you purchase 6 Nexgard: $15 rebate

If you purchase 6 Frontline Gold: $10 rebate
Which preventative medications would you like? Choose all that apply.

Heartgard PlusNexgardFrontline GoldRevolution PlusOther (please specify)
How many doses of Heartgard Plus would you like?

One Month Supply (1 dose)Six Month Supply (6 doses)One Year Supply (12 doses)Other (enter quantity)
How many doses of Nexgard would you like?

One Month Supply (1 dose)Six Month Supply (6 doses)One Year Supply (12 doses)Other (enter quantity)
How many doses of Frontline Gold would you like?

One Month Supply (1 dose)Six Month Supply (6 doses)One Year Supply (12 doses)Other (enter quantity)
How many doses of Revolution Plus would you like?

One Month Supply (1 dose)Six Month Supply (6 doses)One Year Supply (12 doses)Other (enter quantity)
Does {petsName} need refills of any other prescription medications, foods, or supplements?*

YesNo
Please list which prescription(s) you would like refilled, including the prescription name and desired quantity.
i.e. Apoquel 16 mg, 30 tablets
Do you have pet insurance for {petsName}?*

NoYes (please list the company name)
My pet (choose all that apply):*

Competes in dog shows, agility, or other large group competitionsVisits a groomer regularlyAttends classes (i.e. obedience class) regularlyGets boardedAttends doggy daycare and/or visits dog parksTravels to rural areas (i.e. a cabin, a farm)Travels outside MinnesotaGets regularly exposed to new pets (i.e. you are a foster for a rescue and your foster pets interact with your resident pet)Hunts and/or consumes preySpends some time outdoors unsupervisedLives exclusively outdoorsLives exclusively indoorsOther activities that you'd like us to know about (please describe)
Medical History Questions
Is {petsName}'s appetite normal?*

YesNo (please explain)
Have you seen any changes in {petsName}'s water consumption or urination?*

NoYes (please explain)
Has {petsName} experienced any vomiting recently?*

NoYes (please explain)
Has {petsName} experienced any diarrhea, constipation, or other stool abnormalities recently?*

NoYes (please explain)
Has {petsName} had any coughing, sneezing, nasal discharge, or other respiratory issues recently?*

NoYes (please explain)
Have you noticed {petsName} having any limping, pain, stiffness, or other mobility issues?*

NoYes (please explain)
Have you noticed {petsName} having any skin or ear issues such as itching, head shaking, scooting, or chewing at themselves?*

NoYes (please explain)
Has {petsName} developed any new lumps or bumps, or have there been changes in existing lumps?*

NoYes (please explain)
Do you have any additional questions or concerns that you would like to discuss at {petsName}'s visit?*
Consent to Photograph Patients
We may take photos of our patients for many reasons, such as documentation of medical conditions (i.e. skin lesions), photo updates for owners following surgical procedures, or educational photos. Unless specifically discussed with you, these photos are a confidential part of your pet's medical records. Do we have your consent to take photos of your pet?*

YesNo
Social Media Photo Release
We love to share cute photos of our patients via social media! If you choose "yes" below, you are consenting to allow St. Francis Animal Hospital to use photographs of your pet for any lawful purpose, including publicity, illustration, and advertising on our website, Facebook, Instagram, YouTube, and other social media platforms. Do we have your consent to share photos of your pet?*

YesNo
Are there any accommodations we could provide that would improve your visit to St. Francis?
i.e. You would like assistance carrying your pet from the car into the clinic, you would prefer text communication over verbal communication, English is not your primary language and you may need help understanding our communications, etc.
Should be Empty:

Pre-Examination History Form

Patient Information

Fecal Samples

Available Rebates

Medical History Questions

Consent to Photograph Patients

Social Media Photo Release