My Pets Wellness Digital Intake Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
What is your pets name?
What species category is your pet?
Dog
Cat
Bird
Reptile
Small Mammal
Other
What is your pets gender?
Male
Male Neutered
Female
Female Spayed
Where did you acquire your pet?
Shelter
Breeder
Stray
Family/Friend
Rescue
Other
How old is your pet?
Kitten/Puppy
Adult
Senior > 7 Years
The year when your pet joined your household
The month when your pet joined your household
Please Select
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Please list any other pets in the household:
Pet Name
Species
Age
Seen Vet in Last Year?
Pet 1
Dog
Cat
Bird
Reptile
Small Mammal
Other
< 1 Year
1 and 2 Yr
2 and 5 Yr
5 and 8 Yr
8 and 10 Yr
10 and 13 Yr
13 and 16 Yr
> 16 Years Old
Yes
No
Pet 2
Dog
Cat
Bird
Reptile
Small Mammal
Other
< 1 Year
1 and 2 Yr
2 and 5 Yr
5 and 8 Yr
8 and 10 Yr
10 and 13 Yr
13 and 16 Yr
> 16 Years Old
Yes
No
Pet 3
Dog
Cat
Bird
Reptile
Small Mammal
Other
< 1 Year
1 and 2 Yr
2 and 5 Yr
5 and 8 Yr
8 and 10 Yr
10 and 13 Yr
13 and 16 Yr
> 16 Years Old
Yes
No
Pet 4
Dog
Cat
Bird
Reptile
Small Mammal
Other
< 1 Year
1 and 2 Yr
2 and 5 Yr
5 and 8 Yr
8 and 10 Yr
10 and 13 Yr
13 and 16 Yr
> 16 Years Old
Yes
No
Medical Overview
Is your pet taking heartworm medication? If yes, what brand?
No heartworm medication
Heartgard Plus
VetriShield Plus
Revolution Plus
Interceptor
Trifexis
Sentinel
Advantage Multi
Simparica Trio
Other
How often do you give heartworm medication?
Same day every month
Occasionally late/missed doses
Have you missed any doses?
Yes
No
Is your pet taking flea/tick medication?
No flea/tick medication
Bravecto
Frontline
Simparica / Trio
Credelio
Nexgard
Advantage
Advantix
Seresto Collar
Advantage Multi
Revolution Plus
Other
Please list any medications or supplements your pet is taking:
Medication or Supplement Name
Dosage
How often do you give to your pet?
1
2
3
4
5
6
7
Prior Vet Info: Please list the contact information for any previous vet(s) who we might contact for records.
Prior Vet Name
Practice Name
Phone
Email
Vet 1
Vet 2
Upload any medical records, pictures, video or other useful documents
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Is your pet up-to-date on recommended vaccines?
Yes
No
Unsure
Has your pet had bloodwork (CBC, Chemistry, +/- Thyroid Screen) in the last 12 months? (Please email/upload records or bring them with you day of appointment)
Yes
No
Unsure
Has your pet had a professional dental cleaning and examination in the last year?
Yes
No
Animal Activity
Does your dog participate in any of the following:
Daycare
Dog Park
Hiking
Travel
Grooming
Boarding
Does your cat participate in any of the following:
Supervised outdoor time
Unsupervised outdoor time
Boarding
Travel
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Nutrition
What brand/formula are you currently feeding your pet?
What is the consistency of the food?
Dry
Wet/Canned
Both Wet/Dry
Raw
Home Cooked
Other
Have you changed your pet's diet recently?
Yes
No
How did your pet respond to the change?
Positively
Negatively
No Change
Other
How do you feed your pet?
Free Feed
Set Mealtimes
How much food do you give per mealtime?
1/4 Cup
1/3 Cup
1/2 Cup
2/3 Cup
1 Cup
> 1 Cup
Have you noticed any recent weight fluctuations?
No
Yes - Gaining Weight
Yes - Losing Weight
How would you describe your pet’s appetite?
Normal
Increased
Decreased
Ravenous (scarfs food down)
Finicky/Picky
Not Eating
How would you describe your pet drinking habits?
Normal
Increased
Decreased
Not Drinking
Do you give your pet treats? How often?
No Treats
1-2 Treats a day
3-4 Treats a day
5+ Treats a day
What brand/type of treats do you give?
How often is your pet given human food?
Never
Rarely
Occasionally
Once a day
Multiple times a day
List any type of human food you give your pet:
Does your pet have a tendency to eat things they shouldn't? If so, what sort of things?
No, my pet doesn't eat things it shouldn't
Trash
Toys
Grass
Plants
Clothing/Shoes
Have you noticed your pet having issues with bloating or gas?
Yes
No
Select your pets bowel movement type from the images below (click on an image):
Take a picture, video or upload a file showing your pets stool.
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Behavior
Which of the following activities do you do with your pet? Select all that apply
Walking
Running/Off Leash Play
Engaged Playtime (Toys, Fetch, Etc.)
Playtime with other animals
How often does your pet go for a walk?
Few times a week
Daily
Multiple Times a Day
Indoor Only/Does Not Apply
How long is each walk on average?
< 10 Mins
10 to 30 Mins
30 to 1 Hour
1 - 2 Hours
> 2 Hours
Indoor Only/Does Not Apply
How often are they running/off leash?
Few times a week
Daily
Multiple times a day
Indoor Only/Does Not Apply
How long are they off-leash per session? (per hike, dog park, walk)
< 10 Mins
10 to 30 Mins
30 to 1 Hour
1 - 2 Hours
> 2 Hours
Indoor Only/Does Not Apply
How often are they engaged in playtime?
Few times a week
Daily
Multiple times a day
How long does each playtime last on average?
< 1 hour
1-3 hours
> 3 hours
Does your pet engage in playtime with other animals?
Few times a week
Daily
Multiple times a day
How long does each playtime with other animals last on average?
< 1 hour
1-3 hours
> 3 hours
Type of behavioral training
No behavior training
Group classes (pet store, daycare, etc.)
1-1 Professional training
Self-guided training
Is your pet crate trained?
Yes
No
In Process
Are you satisfied with your pet's current level of training?
Yes
No
Does your pet display any of the following anxieties? Select all that apply.
None
Separation anxiety
Thunderstorm anxiety
Sensitivity to loud noises
Situational
Excessive licking of self or inanimate objects
Does your pet display any of the following aggressive traits? Select all that apply.
None
Food Guarding
Toy Guarding
Aggression towards other household animals
Aggression towards unknown animals
Aggression towards you or other household members
Aggression towards strangers
Overly protective of you, resulting in aggressive behavior
Other
Is your pet showing any of the following signs of cognitive dysfunction? Select all that apply
Wandering
Star Gazing
Forgetfulness
Less Aware
Getting lost in familiar spaces
Loss of house training
Does not recognize own name and/or familiar people
Altered sleep-wake pattern
Other
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Wellness Concerns
Do you have any concerns or have you noticed any changes in your pet for any the following? Select all that apply
No Concern - Routine Visit
Eating Habits
Drinking Habits
Vomiting
Diarrhea
Coughing
Sneezing
Abnormal Breathing
Urination (odor, increase in frequency, increase in drinking, accidents in house, straining, etc.)
Reproduction (not spayed/neutered, used for breeding, issue with heat cycles, etc.)
Abnormal Behavior (Anxiety-separation, thunderstorm, sensitivity to loud noises, excessive licking of inanimate objects)
Abnormal Behavior (Aggression-food guarding, toy guarding, aggression towards you, other people, other animals)
Lethargy / Other Concerns
Eyes (discharge, squinting, redness, swelling)
Ears (head shaking, ear scratching, redness, discharge)
Lumps/Bumps (masses, skin tags)
Skin (itching, rashes, redness)
Lameness/limping
Teeth, Breath, Oral Health
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Gastrointestinal - Eating and Drinking
GI Eating/Drinking: Which of the following issues is your pet experiencing? Select all that apply.
Decreased appetite
Not eating
Increased drinking
Decreased drinking
Not drinking
Other
GI Eating/Drinking: When did the issue first start?
< 3 days
4-7 days
1-3 weeks
1-3 months
> 3 months
GI Eating: How has the issue progressed?
Getting better
Getting worse
Staying the same
Waxes and wanes
GI Eating/Drinking: How often has the issue occurred?
This is the 1st time
It's happened once before
It's happened multiple times
GI Eating/Drinking: Have you currently or previously tried to treat the issue?
Yes
No
GI Eating/Drinking: If you tried prior treatments, what were they, and what was the outcome?
Treatment Name
Did the treatment help?
Treatment 1
Yes
No
Somewhat
Treatment 2
Yes
No
Somewhat
Treatment 3
Yes
No
Somewhat
GI Eating/Drinking: Upload any eating or drinking-related photos or video
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Gastrointestinal - Vomiting
GI Vomiting: When did the issue first start?
< 3 days
4-7 days
1-3 weeks
1-3 months
> 3 months
GI Vomit: How has the issue progressed?
Getting better
Getting worse
Staying the same
Waxes and wanes
GI Vomiting: How often has the issue occurred?
This is the 1st time
It's happened once before
It's happened multiple times
GI Vomiting: If you tried prior treatments, what were they, and what was the outcome?
Treatment Name
Did the treatment help?
Treatment 1
Yes
No
Somewhat
Treatment 2
Yes
No
Somewhat
Treatment 3
Yes
No
Somewhat
GI Vomiting: Have you noticed any of the following in the vomit?
Food
Grass
Bile (yellow liquid)
Hair
Blood
Foreign objects
Other
GI Vomiting: Does it seem related to a specific time of day?
Morning
Afternoon / Midday
Night
Not Related
GI Vomiting: Is it related to when your pet eats?
Yes
No
GI Vomiting: Is it related to when your pet drinks?
Yes
No
GI Vomiting: How would you describe your pet's attitude?
Normal
Anxious
Lethargic/Depressed
GI Vomiting: Upload any pictures or video related to vomiting
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Gastrointestinal - Diarrhea
GI Diarrhea: When did the issue first start?
< 3 days
4-7 days
1-3 weeks
1-3 months
> 3 months
GI Diarrhea: How has the issue progressed?
Getting better
Getting worse
Staying the same
Waxes and wanes
GI Diarrhea: How often has the issue occurred?
This is the 1st time
It's happened once before
It's happened multiple times
GI Diarrhea: If you tried prior treatments, what were they, and what was the outcome?
Treatment Name
Did the treatment help?
Treatment 1
Yes
No
Somewhat
Treatment 2
Yes
No
Somewhat
Treatment 3
Yes
No
Somewhat
GI Diarrhea: Have you noticed any of the following in the diarrhea?
Mucous
Blood
Foreign objects
None
Other
GI Diarrhea: Does your pet have a tendency to eat things they shouldn’t? If so, please select
No, my pet does not eat things they shouldn't
Trash
Toys
Grass
Plants
Clothing
Other
GI Diarrhea: How would you describe your pet's attitude?
Normal
Anxious
Lethargic/Depressed
GI Diarrhea: Upload any diarrhea-related photos
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Respiratory
Respiratory: When did the issue first start?
< 3 days
4-7 days
1-3 weeks
1-3 months
> 3 months
Respiratory: How has the issue progressed?
Getting better
Getting worse
Staying the same
Waxes and wanes
Respiratory: How often has the issue occurred?
This is the 1st time
It's happened once before
It's happened multiple times
Respiratory: If you tried prior treatments, what were they, and what was the outcome?
Treatment Name
Did the treatment help?
Treatment 1
Yes
No
Somewhat
Treatment 2
Yes
No
Somewhat
Treatment 3
Yes
No
Somewhat
Respiratory: How would you describe the onset of symptoms?
Occurred gradually over time
Immediate / Sudden
Respiratory: How would you describe the frequency of occurrence? Select all that apply.
Notice more with movement/activity/exercise
During the day
At night
In the morning
Constant
Respiratory: Have you noticed any of the following changes in your pet breathing?
Labored/ Difficulty breathing
Noisy breathing
Congested sounds
Breathing faster than normal
Respiratory: Is the cough or sneeze productive (discharge from mouth or nostrils)?
Yes
No
Respiratory: Appearance of discharge
Clear liquid
Mucus - Green
Mucus - Yellow
Mucus - Clear
Respiratory: Have you noticed any eye discharge?
No
Yes - Green Color
Yes - Yellow Color
Yes - Clear
Respiratory: How would you describe your pet’s energy level?
Normal
Decreased
Lethargic/Depressed
Respiratory: How would you describe your pet’s water intake?
Normal
Drinking Less
Drinking More
Not Drinking
Respiratory: How would you describe your pet’s appetite?
Normal
Eating Less
Eating More
Not Eating
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Illness / Not Feeling Well / Other
Illness: Please describe the illness or concern that you have with your pet:
Illness: When did the issue first start?
< 3 days
4-7 days
1-3 weeks
1-3 months
> 3 months
Illness: How has the issue progressed?
Getting better
Getting worse
Staying the same
Waxes and wanes
Illness: How often has the issue occurred?
This is the 1st time
It's happened once before
It's happened multiple times
Illness: If you tried prior treatments, what were they, and what was the outcome?
Treatment Name
Did the treatment help?
Treatment 1
Yes
No
Somewhat
Treatment 2
Yes
No
Somewhat
Treatment 3
Yes
No
Somewhat
Illness: How would you describe the onset of symptoms?
Occurred gradually over time
Immediate / Sudden
Illness: How would you describe your pet’s energy level?
Normal
Decreased
Lethargic/Depressed
Illness: Have you noticed any changes in weight?
No Change
Gaining Weight
Losing Weight
Illness: Does your pet tire easily?
Yes
No
Illness: Has your pet experienced any recent respiratory issues (coughing, sneezing, gagging)?
Yes
No
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Urinary
Urinary: When did the issue first start?
< 3 days
4-7 days
1-3 weeks
1-3 months
> 3 months
Urinary: How has the issue progressed?
Getting better
Getting worse
Staying the same
Waxes and wanes
Urinary: How often has the issue occurred?
This is the 1st time
It's happened once before
It's happened multiple times
Urinary: If you tried prior treatments, what were they, and what was the outcome?
Treatment Name
Did the treatment help?
Treatment 1
Yes
No
Somewhat
Treatment 2
Yes
No
Somewhat
Treatment 3
Yes
No
Somewhat
Urinary: Have you noticed any of the following issues with your pet’s urination?
No issues with urine
Straining to urinate
Inappropriate urination (accidents in the house)
Blood in urine
Foul odor
Other
Urinary: How would you describe your pet’s frequency of urination?
Normal
Less frequent
More frequent
Urinary: Does your pet seem to be in pain when urinating?
Yes
No
Urinary: How would you describe the amount of urine being produced?
Normal amount
Increased amount of urine
Decreased amount of urine
Not urinating at all
Urinary: Have you noticed your pet straining or displaying a sense of urgency to urinate?
Yes - Straining
Yes - Urgency
No
Urinary: How would you describe the color of the urine?
Normal (light to golden yellow)
Dark Yellow
Cloudy
Red / Blood tinged
Unsure
Urinary: Have you noticed any of these symptoms pertaining to possible incontinence?
Dribbling urine while asleep
Dribbling urine when excited
Dribbling urine throughout the day, pet is unaware that it is happening
Urinary: How would you describe your pet’s attitude/energy?
Normal
More active
Depressed/lethargic
Cat Urinary Questions
Type of Litter
Scented
Non-Scented
Clumping
Non-Clumping
Other
Type(s) of litter box(es)
Open box
Hooded/closed box
Automatic cleaning box
Other
Urinary: Is your cat exhibiting any of the following behaviors? Select all that apply.
Urinating outside of litter box
Sitting in litter box for long periods of time
Vocalizing in litter box
Frequent trips to the litter box
No urine noted after pet leaves litter box
Urinary: How many litter boxes are in your house?
1 per cat
More than 1 per cat
Less than 1 per cat
Urinary: How often do you scoop the litter box(es)?
Twice a day
Once a day
Every other day
A couple times a week
Once a week
Less than once a week
Urinary: How often do you deep clean (empty & wash) the litter box(es)?
Once a week
Every other week
Monthly
Rarely
Urinary: Where is/are the litter box(s) located? Select all that apply
Laundry room
Bedroom
Bathroom
Kitchen
Hallway
Basement
Other
Urinary: Where is your cat urinating outside of the box?
N/A
Vertical surfaces (walls, etc.)
Horizontal surfaces (floors, beds, etc.)
Urinary: What type of surfaces is your cat urinating on?
Soft (towels, blankets, carpet, beds)
Hard (flooring, bathtub, sink)
Variable/all types
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Dermatology
Skin: What issues have you observed? Select all that apply.
Itching
Hair loss
Rash
Oily skin/coat
Dry skin/coat
Dandruff
Redness
Odor
Bumps (Small red raised areas, pimples, warts, etc.)
Other
Skin: When did the issue first start?
< 3 days
4-7 days
1-3 weeks
1-3 months
> 3 months
Skin: How has the issue progressed?
Getting better
Getting worse
Staying the same
Waxes and wanes
Skin: If you tried prior treatments, what were they, and what was the outcome?
Treatment Name
Did the treatment help?
Treatment 1
Yes
No
Somewhat
Treatment 2
Yes
No
Somewhat
Treatment 3
Yes
No
Somewhat
Skin: How often has the issue occurred?
This is the 1st time
It's happened once before
It's happened multiple times
Skin: If reoccurring, how would you describe the frequency of the issue?
Typically only lasts a few days
Typically lasts a few weeks
Year round
Seasonal
N/A
Skin: If seasonal
Spring
Summer
Fall
Winter
Skin: How would you describe the onset of symptoms?
Occurred gradually over time
Immediate / Sudden
Skin: Which symptom did you notice first?
Please Select
Itching
Hair loss
Rash
Oily skin/coat
Dry skin/coat
Dandruff
Redness
Odor
Bumps (Small red raised areas, pimples, warts, etc.)
Skin: On which area of the body did you first notice the issue?
Please Select
Nose
Around eyes
Ears
Neck
Back
Abdomen
Tail
Rump
Legs
Paws
Chest
Muzzle
Groin
Skin: Has it spread to other areas?
Yes
No
Skin: Do any other pets in your house have similar skin issues?
Yes
No
Skin: Have you noticed any of the following on your pet?
Fleas
Ticks
Mites
Lice
Skin: What are you currently using for flea and/or tick prevention?
Oral medication
Topical ointment, applied to skin
Flea/Tick shampoo
Flea spray or powder
None/don't know
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Dental/Oral
Dental: Which of the following issues are you currently noticing? Select all that apply
Odor from mouth
Teeth need cleaning
Mass Around Face or Mouth
Not eating well
Trouble Chewing
Trauma to face
Painful mouth
Drooling
Drainage from cheek, below eye
Other
Dental: When did the issue first start?
< 3 days
4-7 days
1-3 weeks
1-3 months
> 3 months
Dental: How has the issue progressed?
Getting better
Getting worse
Staying the same
Waxes and wanes
Dental: How often has the issue occurred?
This is the 1st time
It's happened once before
It's happened multiple times
Dental: If you tried prior treatments, what were they, and what was the outcome?
Treatment Name
Did the treatment help?
Treatment 1
Yes
No
Somewhat
Treatment 2
Yes
No
Somewhat
Treatment 3
Yes
No
Somewhat
Dental: How would you describe the onset of symptoms?
Occurred gradually over time
Immediate / Sudden
Dental: Upload any pictures or video or take a photo/video using your smart phone.
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Ophthalmology (eye)
Eyes: Which eye is affected?
Right eye
Left eye
Both eyes
Eyes: Which of the following symptoms have you noticed? Select all that apply.
Eyelid Swelling
Squinting
Pain
Redness
Lens appears cloudy
Drainage
Other
Eyes: Select the type of drainage
Clear liquid
Mucous
Other
Eyes: Select the color of the mucous
Gren
Yellow
Black
Red
Clear
Eyes: Are you aware of any recent trauma that may have inflicted eye injury?
No
Dog Fight
Cat Fight
Rough Play
Accident
Other
Eyes: How would you describe the onset of symptoms?
Occurred gradually over time
Immediate / Sudden
Eyes: When did the issue first start?
< 3 days
4-7 days
1-3 weeks
1-3 months
> 3 months
Eyes: How has the issue progressed?
Getting better
Getting worse
Staying the same
Waxes and wanes
Eyes: How often has the issue occurred?
This is the 1st time
It's happened once before
It's happened multiple times
Eyes: If you tried prior treatments, what were they, and what was the outcome?
Treatment Name
Did the treatment help?
Treatment 1
Yes
No
Somewhat
Treatment 2
Yes
No
Somewhat
Treatment 3
Yes
No
Somewhat
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Lameness or Limping
Lameness: Which leg is affected?
Right front
Left front
Right rear
Let rear
Shifting leg / Different leg at different times
Unsure
Lameness: When did the issue first start?
< 3 days
4-7 days
1-3 weeks
1-3 months
> 3 months
Lameness: How has the issue progressed?
Getting better
Getting worse
Staying the same
Waxes and wanes
Lameness: How often has the issue occurred?
This is the 1st time
It's happened once before
It's happened multiple times
Lameness: If you tried prior treatments, what were they, and what was the outcome?
Treatment Name
Did the treatment help?
Treatment 1
Yes
No
Somewhat
Treatment 2
Yes
No
Somewhat
Treatment 3
Yes
No
Somewhat
Lameness: How would you describe the onset of symptoms?
Occurred gradually over time
Immediate / Sudden
Lameness: Do you notice a difference after your pet exercises?
It seems better
It seems worse
No change
Lameness: Have you noticed any pain or sensitivity on the affected leg(s)?
Yes
No
Lameness: Has your pet been exposed to any trauma (rough play, jumping/falling, hit by car)?
Yes
No
Lameness: Have you noticed any of the following?
Reluctance or difficulty going up steps
Reluctance or difficulty going down steps
Reluctance or difficulty jumping up
Reluctance or difficulty jumping down
Difficulty or reluctance to run
Difficulty or reluctance to chase moving objects (cat, ball, other objects).
Slow to get up
Other
Lameness: If possible, please provide a video of the limping. If using a smart phone, you can take a video by clicking the control below.
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Otic (Ear)
Ears: Which ear is affected
Right ear
Left ear
Both ears
Ears: Which of the following symptoms have you noticed? Select all that apply.
Head shaking
Excessive scratching or rubbing of ears
Odor
Irritation/Redness
Discharge
Painful/ Sensitive to touch
Swelling
Other
Ears: If discharge: Please select Color
Yellow
Green
Bloody
Brown/Black
Ears: When did the issue first start?
< 3 days
4-7 days
1-3 weeks
1-3 months
> 3 months
Ears: How has the issue progressed?
Getting better
Getting worse
Staying the same
Waxes and wanes
Ears: How often has the issue occurred?
This is the 1st time
It's happened once before
It's happened multiple times
Ears: If you tried prior treatments, what were they, and what was the outcome?
Treatment Name
Did the treatment help?
Treatment 1
Yes
No
Somewhat
Treatment 2
Yes
No
Somewhat
Treatment 3
Yes
No
Somewhat
Ears: How would you describe the onset of symptoms?
Occurred gradually over time
Immediate / Sudden
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Reproduction
Female - Not Spayed
Repro: When was your pet's last heat cycle?
< 2 months ago
> 2 months ago
Unsure
Repro: What was the date of your pet's last heat cycle?
-
Month
-
Day
Year
Date
Repro: Did you breed her?
Yes
No
Repro: If breed, how many litters has she had?
Female Pet Section
Repro: Have you noticed any vaginal discharge? If so, what color?
No discharge
Green
Brown
Clear
Red
Other
Male Pet Section
Repro: Have you noticed any discharge from the penis sheath? If Yes, what color
No discharge
Green Brown
Clear
Red
Other
Both Male and Female Section
Repro: How would you describe your pet’s activity level?
Normal
Increased
Decreased
Depressed/Lethargic
Repro: Have you noticed any of the following? Select all that apply
Increase in drinking
Increase in urination
Inappropriate urination (urinating in the house)
Changes in appetite
Hair loss
Odor
Unkempt coat
Changes in Behavior
Aggression
Restlessness
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Anxiety
Anxiety: If you have other pets in the house, describe the social interactions among your pets
All animals are friendly towards each other
All animals tolerate each other, no issues
Dogs do not get along
Cats do not get along
Dogs and Cats do not get along with each other
Mixed. Some problems.
Other
Anxiety: For dogs, how long does your pet spend outside each day?
25% of the day
26% to 50% of the day
51% to 75% of the day
76% to 100% of the day
Access to yard with doggy door
Pet is in fenced-in yard, not allowed inside
Only for potty breaks
Other
Anxiety: For cats, how would you describe your pet’s outdoor time?
Cat is indoor only
Goes out during the day, comes back at night
Outdoor only
Supervised outdoor time
Anxiety: Where is your pet while you are at work?
Outside
Inside with access to the outside (dog/cat door)
In a crate
Daycare
I am home with my pet all-day
Other
Anxiety: Have you recently obtained a new pet? If yes, how has your resident pet responded?
Yes
Positively
Negatively
Indifferent
Anxiety: Please select all of the following behaviors that apply to your pet.
Destructive behavior (chewing/clawing at doors, walls, carpet, drapes, etc.)
Vocalization (excessive vocalizing)
Bathroom accidents in the house when you’re away
Fear of loud noises
Fear of thunderstorms
Fear of fireworks
Avoiding housemates
Hiding
Trembling
Teeth chattering
Other
Anxiety: When did you first notice your pet start to display anxious behaviors?
Present since owned
Started a few months after owning
Recent change
Anxiety: Who is the primary caretaker of the pet?
You
Your spouse
A child
Anxiety: What type of area are you in?
City
Suburb
Rural
Anxiety: What type of home do you have?
House
Apartment
Townhome
Other
Anxiety: If you tried prior treatments, what were they, and what was the outcome?
Treatment Name
Did the treatment help?
Treatment 1
Yes
No
Somewhat
Treatment 2
Yes
No
Somewhat
Treatment 3
Yes
No
Somewhat
Anxiety: Please upload any video of the behavior if possible
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Aggression
Aggression: Do you have other pets in the house?
Yes
No
Aggression: If you have other pets in the house, describe the social interactions among your pets
All animals are friendly towards each other
All animals tolerate each other, no issues
Dogs do not get along
Cats do not get along
Dogs and Cats do not get along with each other
Other
Aggression: For dogs, how would you describe your pet’s outdoor time?
25%
26% to 50%
51% to 75%
76% to 100%
Pet is in fenced in yard, not allowed inside
Only for potty breaks
Other
Aggression: When did the aggressive behavior begin?
Pet has had issue since owned
Started recently- within the past few weeks/months
This is the first occurrence
Aggression: Has your pet bitten and broken skin? If yes, how many times?
No
This is the first time
Once before
Multiple times
Aggression: Is the problem getting worse
Yes
No
Aggression: How often are aggressive acts seen?
Daily
Weekly
Monthly
Sporadic
Specific Situations
Aggression: Who is the pet aggressive towards?
Other Pets
Adults in your household
Children in your household
Adult Strangers
Children Strangers
Other
Aggression: Do you discipline your pet for aggression? If yes, select how
Say "No"
Place in yard
Place in crate
Place in another room
Firm commands
Yell
Physical discipline
Other
Aggression: How does your pet respond to discipline?
Positively
Negatively
Aggressively
Fearful
Aggression: Have you trained your pet for any of the following?
Obedience training
Protection
Hunting
Other
Aggression: Does your pet obey basic commands
Yes
No
Aggression: Who is the primary caretaker of the pet?
You
Your spouse
A child
Aggression: What type of area are you in?
City
Suburb
Rural
Aggression: What type of home do you have?
House
Apartment
Townhome
Other
Aggression: If you tried prior treatments, what were they, and what was the outcome?
Treatment Name
Did the treatment help?
Treatment 1
Yes
No
Somewhat
Treatment 2
Yes
No
Somewhat
Treatment 3
Yes
No
Somewhat
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Body Map
Lumps/Bumps: Type the letter code corresponding to the bump, mass, or lesion location from the chart above. For example F4 - Bump:
Letter Number Code
Description
Location 1
Location 2
Location 3
Location 4
Lumps/Bumps: How many days ago did you notice the mass?
Lumps/Bumps: Since noticing the mass, how has it progressed?
Increasing in size
Decreasing in size
Stays the same
Lumps/Bumps: Has this mass been aspirated (sampled) previously by a veterinarian?
Yes
No
Lumps/Bumps: Please either upload or bring any records related to samples with you to the appointment.
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Final notes, questions, or other information for your veterinarian:
Should be Empty: