Stack Vet - Pre-Examination Questionnaire

1

Have you already scheduled your pet’s appointment?* This field is required.

YESNO

2

If you are arriving for a fit-in appointment, please text 315-470-2278 or call us at 315-478-3161 to let our team know you have arrived, and wait in your vehicle for further instruction.

3

If so, list date and time of scheduled appointment.* This field is required.

Date

Hour

Minutes

4

Client/Pet Information* This field is required.

Client First Name

Client Last Name

Client Email

Client Phone Number

Pet(s) Name(s)

5

Would you like to remain in your vehicle for your pet(s) appointment?* This field is required.

YESNO

6

What type of appointment did you schedule for your pet(s)* This field is required.

Wellness (Physical Exam, Vaccines, Bloodwork, etc.)

Sick or Recheck

7

How would you like to receive routine lab work results?

I am comfortable receiving routine lab work results by email

I would like to receive routine lab work results by phone

No preference

8

Email addressPlease enter your email address to receive routine lab work results.

example@example.com

9

Phone NumberPlease enter your phone number to receive routine lab work results.

Please enter a valid phone number.

10

Has your pet exhibited any changes or shown any symptoms?* This field is required.Please select all that apply

Water intake or appetite?

Bowel movements or urinary habits?

Any vomiting, diarrhea, coughing, or sneezing?

Any lumps, bumps, scratching or itching?

Any changes in mobility? Any limping or pain?

None of the above

11

Please describe changes in water intake or appetite.* This field is required.

12

Please describe changes in bowel movements or urinary habits.* This field is required.

13

Please describe vomiting, diarrhea, coughing, or sneezing.* This field is required.

14

Please describe lumps, bumps, scratching or itching.* This field is required.

15

Please upload photo (Any lumps, bumps, scratching or itching)

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

16

Please describe changes in mobility, limping, or pain.* This field is required.

17

Upload a video (changes in mobility, any limping or pain)

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

18

Do you have any concerns you’d like to discuss during this visit?* This field is required.

YESNO

19

Please describe the concerns you would like to discuss.

20

In the past six months, has your pet been seen for this issue in our office? * This field is required.

YESNO

21

Describe your concerns? When did it start? Has it gotten better or worse?

22

Will your pet need a nail trim or anal glands expressed during this visit?*Optional

Nail Trim

Anal Glad Expression

Both

None

23

Does your pet have any allergies or reactions to medications?* This field is required.

YESNO

24

If yes, list all known allergies and reactions

25

Is your pet taking any daily medications or supplements?* This field is required.

YESNO

26

List all medications and supplements.

27

Is your pet taking flea/tick and heartworm preventatives?* This field is required.

YESNO

28

If yes, which medication(s), and when was the last dose?

29

Do you need any medication or supplement refills?* This field is required.

YESNO

30

If yes, which medication(s), and amount requested (is it possible for our clients to upload a photo of the bottle of meds?)

31

What brand of food(s) are you feeding?

How much and how often?

32

Would you like to upload a photo of the food bag or can?

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

33

Does your pet spend abundant amount of time outdoors?* This field is required.

Often

Sometimes

Never

34

Is anyone in your household allergic to peanut butter? (We will not offer peanut butter as a treat if there is a household allergy)* This field is required.

Do NOT give my pet peanut butter

It IS okay to give my pet peanut butter