COMPLETE OR ANNUAL HEALTH EVALUATION - Virtual Check-In
The following health history/risk assessment is a comprehensive look at your pets most recent health history at home. If we haven't collected this information on your pet in more than 18 months, or if this is the first time we are getting to know your pet, this form is for you and your pet family. It will take about 10-20 minutes to thoughtfully complete, and is best completed by your pet's primary caregiver. Completing this intake to the best of
Pet's Primary Adult Caregiver - Full Name
*
First Name
Last Name
Pet's Other Adult Caregiver(s) if Any
Name(s)
Valid Caregiver E-mail
Pet Patient's Name
*
Appt Date If Known
-
Month
-
Day
Year
Date
Ownership Status
*
Briefly describe the breeder, rescue or other circumstances under which this pet was obtained. Please estimate the length of of your ownership. If this patient was obtained outside of Evansville, Indiana, where did they live before? Has there been any interruption In ownership (extended stays elsewhere, or with other persons lasting more than a few weeks)? With new patients, or patients regaining a relationship with our clinic, this can be helpful when evaluating risk of certain infectious or non-infectious disease.
If different than the caregiver(s) listed above, who is the adult person presenting this pet patient to Highland during the appointment/check in time?
First Name
Last Name
Goals for today's visit
*
List your understanding of the purpose of this appointment or visit, and/or any questions you have about the appointment.
Back
Next - General Information
GENERAL INFORMATION
Patient Species
*
Canine (Dog)
Feline (Cat)
Date of Birth (Estimate Ok)
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Age of Patient - Estimate Ok
*
Indicate above how old your pet may be in terms of weeks, months, or years
Pet's Biological Gender & Reproductive Status
*
Male - Intact, less than 1yr old
Male - Intact, >3yrs old
Female, Intact, less than 1yr old
Female, Intact >3yr old
Neutered Male
Spayed Female
Female - Spayed Status Unknown
Name of veterinarian or other preferred veterinary professionals you have most recently seen or are currently seeing
Lifestyle
*
Indoor Exclusively (uses litter pan or pee-pad to eliminate)
Indoor/Lanai
Indoor/Outdoor to Eliminate or Exercise
Outdoor Mostly or Exclusively
Canine Activities or Occupation
My Dog is a Companion or Pet
Doggie Daycare
Visits Pet Store
Visits or Stays in Home with Different Pets
Pets from Other Houses Frequent Our Home
Attends Dog Park
Goes to Puppy School/Class or Adult Obedience Training
Attends Boarding or Grooming Facilities
Competes in Organized Agility, Hunting or Herding
Competes in Shows
Travels with the Family
Hunts/Hikes/Goes Fishing or Camping
My Dog Likes to Swim
We Feed our Pet(s) Outdoors
My Dog is a Working Animal : Guardian, Hunting, Herding or Rescue
My Pet is a Working Animal: Medical or Emotional Support
This Patient Lives in an Institution (such as a nursing care facility or school)
This is a Foster Animal
We Foster other Animals
Patient is or will be a Breeding Animal
Feline Activities or Occupation
At Home Exclusively (Pet Sitter Only if We are Away)
Visits or Stays in Home with Different Pets
Pets from Other Houses Frequent Our Home
Visits Pet Store (i.e. PetSmart Window)
Goes to Kitten Socialization Class
Attends Boarding or Grooming Facilities
Competes in Shows
Travels with the Family
We Feed our Pet(s) Outdoors
My Pet is a Working Animal: Medical or Emotional Support
This Patient Lives in an Institution (such as a nursing care facility or school)
This is a Foster Animal
Companion or Pet Cat
We Foster other Animals
Barn Cat
Patient is or will be a Breeding Animal
Patient is a Proven Mouser
Lifestyle I - Surrounding Environment
*
Suburban (Neighborhood - Some trees and wildlife)
Urban (Cityscape/Downtown - Lots of Concrete)
Rural (Some Acreage, Some Wildlife, Maybe Livestock)
The American Animal Hospital Association advises us to personalize your pet's health risk assessment to prevent infectious diseases, external or internal parasites, or treat infectious illness that may be more prevalent based on your homes surrounding ecosystem, climate, and exposure to housemates or wildlife which may contact the grass and dirt of your yard. Please select the option that best matches your surrounding location.
Lifestyle III - Water Borne Illness/Injury
There is no body of water (large or small) within twenty feet of my home and my pet will not have contact with any body of water
My pet is a foster pet or newly adopted as a stray its history is unknown
There is a body of water (large or small) within twenty feet of my home (mosquito flight distance), but my pet will not have physical contact with the water.
My pet may have contact sometimes with a body of standing water
Lifestyle II - Housemates and Animal Neighbors
*
Other pets - Dog(s)
Other pets - Cat(s)
Other pet(s) - Small Mammals
Livestock on Property - No Interaction
LIvestock on Property - Minimal or Moderate Interaction
Family Feeds Feral Cats or Stray Animals
Racoons are trees or yard on occasion
Squirrels, Skunks, or Other Small Mammals
Wild Canines (Coyotes or Foxes)
Deer in Yard
Wild Turkeys in Yard
None or N/A
Back
Next - Resources
Resources
Medication I
*
My pet is currently taking, or is routinely prescribed prescription medication other than routine prevention (i.e. vaccines, heartworm/flea/tick prevention)
My pet is not taking nor are they prescribed any medications other than routine prevention (i.e. vaccines, or heartworm/flea/tick prevention)
Medication II
Please list all routinely prescribed medication other than routine prevention and please state the most recent successful dose or in clinic administration (date and or time)
Medication III
I will need refills of this medication today, or soon
I need help with compliance--this medication is difficult to give or fit in with our routine (i.e. compounded to flavored liquid, chewable tablet, or topical if possible)
I would like this medication sent to our door via your online pharmacy
Vitamins, Supplements, Over-the-Counter Remedies or Medications
*
My Pet Does Not Take Vitamins, Supplements, or OTC Medications
My Pet Takes Vitamins, Supplements or OTC Medications
I Need Refills or Guidance from The Clinic
My pet takes an over the counter flea/tick preventative
If available, would like these OTC medications sent to our door via your online pharmacy
Vitamins, Supplements, Over-the-Counter Remedies or Medications II
Please list all OTC medications, preventatives, vitamins or nutritional/herbal supplements or remedies that your pet takes at home.
Heartworm Test Status
My dog tested negative for Heartworms LESS Than 180 Days Ago
My dog tested negative for Heartworms, MORE than 180 Days, but LESS than 365 days ago
My dog has not had a Heartworm Test within the last year AND they are over 6 months of age
My Dog is a Heartworm Positive Patient and is not Yet in Treatment Under a Veterinarian
My Dog is a Heartworm Positive Patient But Is In Treatment with A Veterinarian
My Dog Completed Heartworm Treatment Less Than 1 Year Ago
Feline Retrovirus (FLV/FIV) and Heartworm Test Status
My cat tested negative for FIV and FLV 181-365 days ago and has not been exposed to new cats, nor do they roam outside.
My cat tested negative for FIV and FLV, more than 365 days ago, but has never been exposed to new cats, nor roamed outdoors since this test was performed
My cat has not, to my knowledge been tested for FIV or FLV
My cat is an FIV positive patient
My cat has tested positive for FLV
My cat has tested positive for Feline Heartworm's Disease
My Dog's Heartworm Prevention of Choice is:
*
ProHeart 12 - https://tinyurl.com/proheart12
ProHeart 6 - https://tinyurl.com/proheart6
Interceptor Plus - https://tinyurl.com/HVCinterceptorplus
Simparica Trio - https://tinyurl.com/HVCsimparicatrio
My dog is not on heartworm prevention currently
My Dog's Heartworm Prevention II
If possible, I would like refills from your online pharmacy and prescription management system: https://tinyurl.com/HVCcovetrusHW
My Dog's External Parasite Prevention (Flea/Tick Etc) of Choice is:
*
Bravecto 3 Month Tablet - https://tinyurl.com/HVCBravecto
Provecta Advanced - https://provectapet.com/
Simparica Trio - https://tinyurl.com/HVCsimparicatrio
My dog is not on external parasite prevention currently
My Cat's Parasite Prevention (Flea/Tick, Heartworm, Ear Mites Etc) of Choice is:
*
Bravecto 2 Month Topical Solution - https://tinyurl.com/HVCCatBravecto
Provecta II for Cats- https://provectapet.com/
Revolution Plus - https://www.zoetispetcare.com/products/revolution-plus
My cat is not on any parasite prevention
My Dog's External Parasite Prevention (Flea/Tick, Etc) II
If possible, I would like refills from your online pharmacy and prescription management system: https://tinyurl.com/HVCcovetrusFleaTick
My Cat's Parasite Prevention (Heartworm, Flea/Tick, Etc) II
If possible, I would like refills from your online pharmacy and prescription management system: https://tinyurl.com/HVCcovetrusCatPara
External Parasite Prevention - Housemates - Which Pets Are Treated?
*
There are no other pets in the home
Dog(s)
Cat(s)
Small Mammals (Ferrets, Rabbits, Rodents)
External Parasite Prevention - Housemates II - Which Pets Are NOT Treated
Please list any of the pets indicated above who are NOT receiving flea or tick prevention at this time.
Resources - Current Dietary or Meal Plan At Home
*
Please list all types of foods or treats (over the counter, prescription, homemade, or "people food"), that the patient receives in an average day or week. For each food or treat, please list the amount the patient receives on an average day or week, and the times during the day that your patient receives a meal. If food is left throughout the day in a feeder simply list the type and brand of food, and type "free fed" to indicate meal times.
Resources - Current Dietary or Meal Plan at Home - Dog
My Pet's Diet is currently a Prescription Diet, and I am interested in receiving it at home via: https://tinyurl.com/HVCDogFoodCovetrus, Hills at Home, or Purina Vet Direct
Resources - Current Dietary or Meal Plan at Home - Cat
My Pet's Diet is currently a Prescription Diet, and I am interested in receiving it at home via: https://tinyurl.com/HVCCatFoodCovetrus Hills at Home, or Purina Vet Direct
Resources - Drinking Water - Cat
My cat shares a water bowl or fountain with dogs
My cat's water bowl or fountain is separate from My Dogs Water
I have one water fountain or bowl for cats, and there are less than three
I have more than water fountain or bowl for more than three cats
Resources - Housemates - Safe Zones for Cat(s)
I provide elevated "safe zones" for my cat who lives in a multiple pet household
I do not have other pets, but provide elevated resting areas for my cat for enrichment
I have a baby gate so that my cat(s) can rest in an area away from my other pet(s)
I do not have other pets, or just another cat, and they get along well - do not seem to need any safety zones
Number of Cats Sharing Litter Pans
How many cats total, in this household are there, who aren't quarantined from each other, and are sharing litter resources? Please Include this patient in the number of cats.
Number of Available Litter Pans
For the group above, including this patient, how many litter pans are available?
Litter Hygiene
How often are the litter pans scooped? What kinds of litter are used most often in the house. If a "litter buffet" method is used, please name the brands or types used. A litter buffet is a system which aids in fighting litter aversion where there are different litter pan types and different litter types used in different areas of the household. Please also indicate if the litter pan, is located close to a cat's food and water resources, or dogs or young children who may disturb litter pan use.
Resources - Exercise
Briefly describe your pet's activity in a typical day, whether they have puzzles or toys, are walked by you or a sitter, participate in activities in day care, or if they seem to have difficulty exercising.
Resources - Sleeping Quarters & Habits
*
How many hours of the day does your pet receive rest, on average, and where does your pet sleep. Please indicated whether your pet is sleeping more or less in a way that concerns you. If your pet is unable to get adequate rest, please discuss that here (i.e. pacing/itching/whining etc). If your pet is older than 8yo please indicate whether your pet is overactive and rests less.
Back
Next - Condition & History
Health Conditions and Health History
Prior Known Illness(es)/Surgery(ies)
*
Please list any illnesses or surgeries that your pet may have on record at a facility OTHER than HIGHLAND VETERINARY CLINIC. If none or unknown to you at this time, simple state "none" or "unknown"
Chronic problems/conditions & ongoing treatment
*
Please list any ongoing problems or conditions that your you are managing for your pet or treating for your pet OTHER than what is on record at HIGHLAND VETERINARY CLINIC. If none, simple state "none"
When, to your knowledge was your pet's last Heat Cycle?
If you have never observed a heat cycle, simply state "unknown"
Allergy History as Diagnosed by a Veterinarian - Select all that apply
*
No Known Allergies
Atopy (inhaled-Seasonal or Otherwise)
Flea Allergy
Food Allergy
Vaccine Reactivity
Patient Takes Immunotherapy or has An Allergy Plan
Current Apparent Attitude/Disposition
*
Bright. Alert, Responsive
Quiet, But Alert, Responsive
Depressed/Lethargic, But Aware
Moribund and Listless, May or May Not be Respond Normally
Vomiting?
*
No
Yes, every few hours, within the last 24 hours
Yes, every so often over the last week
Yes, every few weeks, my pet vomits food.
You Indicated that Your Pet is Vomiting on an Acute or Chronic Basis - Please select all that apply
Foamy Vomit
Clear Liquid or Mucoid Vomit
Mushy, Partly Digested Food
Regurgitation - Food Pieces/Not Digested
Vomiting Water
White Vomit
Yellow Vomit
Brown Vomit
Black Vomit
Green Vomit
Objects or Material In Vomit (Describe Under "Other")
Worms in Vomit
You Indicated That Your Pet Has Been Vomiting on an Acute or Chronic Basis
Please briefly describe what you think may have caused or does cause your pet to vomit, or the environmental circumstances or activity that seems/seemed to have happened prior to your pet's vomiting episode(s)
Coughing?
*
My Pet isn't Coughing
My Pet is Coughing (Acute Onset)
My Pet is Coughing (Chronically-Previous Diagnosis of Disease)
You Indicated That Your Pet Has Been Coughing on an Acute or Chronic Basis
Please indicate the onset or estimate roughly how long this cough has been present. Briefly describe what you think may have caused or does cause your pet to cough, or the environmental circumstances or activity that seems/seemed to have happened prior to your pet's coughing episode(s), including times of day or after activity.
Sneezing?
*
My Pet Does Not Seem To Sneeze More Often Than is Normal
My Pet Seems to Sneeze More Often Than is Normal
You Indicated That Your Pet Has Been Sneezing on an Acute or Chronic Basis
Please indicate the onset or estimate roughly how long this persistent sneeze has been present. Briefly describe what you think may have caused or does cause your pet to sneeze, or the environmental circumstances or activity that seems/seemed to have happened prior to your pet's sneezing episode(s), including times of day or after any particular event or activity occurs in the home.
Respiratory Health Screen
*
My Pet Seems to Be Breathing Normally
My Pet has a Previously Diagnosed Respiratory Condition But it is Controlled/Unchanged
My Pet has a Previously Diagnosed Respiratory Condition and Their Breathing Seems to have Declined
My Pet's Making Abnormal Sounds When Breathing
My Pet's Respiratory Rate or Effort is Abnormal
You Indicated That Your Pet Has Struggled with Respiratory Issues
Please indicate the onset or estimate roughly how long this abnormal condition has been present. Briefly describe what you think may have caused or does cause your pet's breathing difficulties, or the environmental circumstances or activity that seems/seemed to have happened prior to your pet's struggle to breathe or episode(s) of abnormal breathing, including times of day or after any particular event or activity occurs in or around the home.
Does anyone in the family smoke cigarettes or marijuana indoors?
*
Yes
No
We aren't really concerned with vapor pen products nor edible consumption of CBD oil or THC--just exposure to indoor second hand smoke, relative to your pet's respiratory condition(s) and treatment right now.
Back
Next
Using the chart above please rate your pet's level of itching or self grooming at this time.
*
0
1
2
3
4
5
6
7
8
9
10
Normal or None
Severe Itching
0 is Normal or None, 10 is Severe Itching
Describe Itching or Excessive Self Grooming Pattern
If your pet is experiencing a level of itch beyond the level of 2, please indicate the onset or estimate roughly how long this itching condition has been present. Briefly describe what you think may have caused or does cause your pet to itch, or the environmental circumstances or activity that seems/seemed to have happened prior to your pet's itching or episode(s) of chronic itching, including exposure to any plants, other animals, seasons, proteins or carbohydrate sources.
Oncology Screen
My pet has no new lumps nor bumps in the skin, nor underneath the skin that concern me at this time.
My pet has a new lump or bump in the skin or underneath the skin.
My pet has a lump or bump in or under the skin which has been seen before by a veterinarian, but we are certain there have been no changes.
My pet has a lump or bump in or under the skin which has been seen before by a veterinarian, but we think it may have changed in character, shape or size and it needs monitoring.
My pet has a lump or bump in or under the skin which has been seen before by a veterinarian, but we'd like a second opinion or second look.
Oncology Screen II
Your response has indicated the need to have a first time look, or fresh look at new growth or a previously diagnosed benign tumor in or under your pet's skin. Please indicate how long the growth may have been present, or what changes you've noticed in any old growths you would like examined.
Oncology Screen III
Browse Files
If you have a photo of a lesion, or lump or bump that you would like to upload to your pet's chart, please feel free to do so.
Cancel
of
Back
Next
Parasite Screen - I have noticed the following within the last month:
None - I have seen no parasites in relation to my pet
Unknown Parasites on the Skin
Parasites in the Stool
Fleas
Ticks
Mites
Biting Flies or Evidence of "Fly Strike"
Regarding Your Pet's Appetite and Levels of Thirst
*
My Pet's Appetite Seems Normal
My Pet is Drinking Normally
My Pet's Appetite Seems to Be Increased or Excessive
My Pet's Appetite Seems to Be Decreased
My Pet Has Refused all Foods and Treats for More Than 24hrs
My Pet's Drinking Habits Seems to Be Increased or Excessive
My Pet's Drinking Habits Seem to be Decreased
My Pet Has Refused Water for More than 24hrs
Changes or Abnormalities in Appetite and Fluid Intake
Your response has indicated a change in your pet's appetite level or fluid intake. Please indicate how long this has been going on, or what circumstances you've noticed surrounding this change
Regarding Your Pet's Bowel Movements
*
My Pet's Bowel Movements Seem Normal in Frequency
My Pet's Bowel Movements Seem Normal in Color
My Pet's Bowel Movements Seem Normal in Consistency and Composition
My Pet's Bowel Movements have Increased in Frequency
My Pet's Bowel Movements have Decreased in Frequency
My Pet Has Not Had a Bowel Movement in More Than 24hrs
My Pet Has Been Straining to Defecate
My Pet's Stool Seems Very Hard or Dry
My Pet's Stool Seems very Soft or Lacks Shape
My Pet Has Diarrhea
My Pet's Stool Color Seems Abnormal (see above)
I haven't observed my pet's bowel movements in the last 2 to 4 days.
My Pet Seems Chronically Irregular (see comments)
Fecal Score
*
Using the chart provided, please assign the most current fecal score for your pet.
Changes or Abnormalities in Bowel Movements
Your response has indicated a change or abnormalities in your pet's bowel movements . Please indicate how long this has been going on, or what circumstances you've noticed surrounding this change
Regarding Your Pet's Urinary Movements
*
My Pet's Urination Seems Normal in Frequency
My Pet's Urine Seems Normal in Color
My Pet's Urination Seems Normal in Clarity
My Pet Seems to be Urinating More Frequently
My Pet Seems to be Urinating Less often
My Pet Has Not Urinated in More Than 12-24hrs
My Pet Has Been Straining to Urinate
My Pet Seems to be In Pain When Urinating (Vocalizes etc)
My Pet's Urine Appears Dark To Me
My Pet's Urine Appears Cloudy to Me
I have Seen Blood in My Pet's Urine
I haven't observed my pet's urinary habit in the last 12-24hrs
My Pet is Urinating When They Are Sleeping
My Pet's Urine Seems to have a Foul or Strong Odor
My pet's housetraining or litter pan training is failing (Urinating or Defecating Inappropriately)
Changes or Abnormalities in Urinary Movements
*
Your response has indicated a change or abnormalities in your pet's urinary habits that you would like to address. Please indicate how long this has been going on, or what circumstances you've noticed surrounding this change.
Back
Next - Pain & Mobility Screen
Pain & Mobility Screen
Gait and Mobility
My Pet is Able to Rise from Any Position without Effort or Pain
My Pet Is able To Walk and Run As Expected
My Pet Has a Previous Diagnosis Which Impairs Their Mobility but There has Been No Decline
My Pet Has a Previous Diagnosis Which Impairs Their Mobility And There Has Been a Decline
My Pet is Limping intermittently
One or More of My Pet's Limbs is Constantly Non-Weight Bearing
My Pet Rises With Some Effort and "Stiffness", But Does Not Limp
Right Foreleg Lameness or Involvement
Left Foreleg Lameness or Involvement
Right Hind Leg Lameness or Involvement
Left Hind Leg Lameness or Involvement
Pain Scale
*
Using the graph above, please rate your pet's pain from 0-4, with 0 being equivalent to no pain, and 4 being the most severe pain.
Problems with Gait, Pain, or Mobility
*
Your response has indicated a problem with pain, stiffness, or mobility that you would like to address. Please indicate how long this has been going on, or what circumstances you've noticed surrounding this problem.
Back
Next - Patient Behavior & Finish
Patient Behavior & Finish
Sometimes changes in a pet's behavior can indicate pain, illness, or injury. We have just a few more questions to ensure that we have as much information we can use to help your pet. Remember they can't speak and tell us what's wrong, so we count on you and thank you for your patience!
Behavioral Screen
*
My Pet is Acting and Behaving Normally, In General, For Him/Herself
My Pet does Not Seem to Have Any Troubling Behaviors That I Would Like to Discuss
My Pet Seems Generally More Anxious Than Normal
My Pet Has Developed a Phobia or Specific Anxiety I would like to Discuss
My Pet Has Displayed Aggression, But This is Not New
My Pet Is Aggressive Toward Other People Inside the Family
My Pet is Aggressive Toward Other People Outside of the Household
My Pet is Aggressive Toward Other Animals Inside the Household
My Pet is Aggressive Toward Other Animals Outside of the Household
My Pet is Territorial Over Their Resources (Food, Toys, Kennel, Etc.)
My Pet Has Displayed Submissive Aggression (Is Aggressive During Anxiety Inducing Moments)
Separation Anxiety - My Pet Destroys My Property, Causes Self Harm, or Vocalizes Excessively When I Am Gone from the House
My Pet Has Noise Phobia
My Pet Acts Very Anxious or Aggressive When Restrained
Concerns with Behavior or Emotional Wellness
*
Your response has indicated your pet may have a struggle with his/her emotional wellness or have a behavioral concern that you would like to address, or that may help us handle your pet's care as comfortably as possible. Please indicate how long this has been going on, or what circumstances or activities you've noticed surrounding this problem. In general, if you have any handling or preferences that you think work best for your pet you may also list or discuss them there.
Medical Progress Photo or Video
Browse Files
If you have a photo, video, or file which you feel is relevant to your visit today, please upload here
Cancel
of
Finish
Should be Empty: