In Home Assessment Questionnaire
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Preferred method of communcation:
if unknown, give best estimate
can put feline for cat, mixed for unknown dog breed, etc
Pet's gender & if spayed or neutered:
ex: male, neutered
Please go into as much detail as you would like - the more information we have, the better we can prepare for your appointment.
What are your goals for the consultation? What are your major concerns? Are you considering humane euthanasia, or are you only interested in pursuing hospice/palliative care at this time?
History of the current problems: How long have the major problem(s) been going on?
What diagnostic tests and treatments were done, with what results? Has your pet had a bad reaction to or side effects from any medications? Have any worked very well for your pet?
Please list your pet's current medications (include DOSE & FREQUENCY), supplements, and diet.
Any vomiting/diarrhea/coughing/excessive urination/excessive drinking/poor appetite?
When was the last visit to the pet's primary and/or specialty veterinarian, what is the vet's and their clinic's name, and is it ok to contact them for records? If you have test results, please email them to firstname.lastname@example.org.
Are there multiple caregivers for your pet, and do any have medical experience? Please make sure all caregivers can attend the appointment. How many hours a day is your pet left unattended? What would be the most frequently you are able to administer medications (every 4 hours? 12 hours?)? Would you be comfortable (or at least able to) administering injections to you pet if we taught you?
Are there other pets of concern in the household? Are there any daily challenges in taking care of your pet? Any difficulty in terms of giving medications? What medication route works best for your pet (pills, liquids, injections, etc)?
Is there anything else you feel is important for us to know, or specific questions you need answered?
Should be Empty: