PEDIATRIC EVALUATION - Virtual Check-In
Our Preventative Healthcare plans allow our attending veterinarians to offer a reward program for preventative screening. Your veterinarian will evaluate your pet’s condition, breed, age, medical history and lifestyle to create a Health Risk Assessment (HRA)— identifying your our pet’s risk for potential disease. During this evaluation and family discussion we'll create actionable items which vaccinate your pet against infectious disease and allow us to manage other non-infectious diseases or conditions should they occur.
Pet's Primary Adult Caregiver - Full Name
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First Name
Last Name
Pet's Other Adult Caregiver(s) if Any
Name(s)
Valid Caregiver E-mail
Pet Patient's Name
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Appt Date If Known
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Month
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Day
Year
Date
This Patient
Is coming to Highland Veterinary Clinic for the First Time
Is coming to Highland Veterinary Clinic for the First Time but has received vaccinations before from a breeder, rescue, or other vet facility
Has been to Highland Veterinary Clinic for an Initial Exam, This is a repeat visit or booster visit
Past Pertinent History or Current Concerns
Any prior boosters, medical conditions or care, de-worming? Please list dates here and upload any documents in the next field
You may upload any history documents here--or just feel free to bring them along
Browse Files
Documents for patients with a more involved or complex medical history should be brought along for scanning.
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Ownership Status
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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
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List your understanding of the purpose of this appointment or visit, and/or any specific questions you have about the appointment.
New, Most Pressing Concerns?
Are there any pressing medical or training questions or concerns since your pet's initial visit?
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Next - General Information
GENERAL INFORMATION
Patient Species
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Canine (Puppy)
Feline (Kitten)
Date of Birth (Estimate Ok)
Please select a month
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Month
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Day
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Year
Age of Patient - Estimate Ok
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Indicate above how old your pet may be in terms of weeks or months
Pet's Biological Gender & Reproductive Status
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Male - Intact
Female, Intact
Early Neutered Male (8-10wks)
Early Spayed Female (8-10wks)
Spayed Female (4+ Months Old)
Male (4+ Months Old)
Reproductive Care Plan
Plan to be Spayed/Neutered 4-6months Old
Plan to be Spayed/Neutered 6-12months Old
Unsure of Spay or Neuter Plan At This Time
Breeding Planning - Would Like to Discuss Pre-Breeding Plan
Considering Breeding - No Plan in Place Yet
Other
Lifestyle Plan This Year
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Indoor Exclusively (uses litter pan or pee-pad to eliminate)
Indoor/Lanai or Enclosed Porch
Indoor/Outdoor to Eliminate or Exercise
Outdoor Mostly or Exclusively
Planned Puppy Activities or Occupation/Training
My puppy is a companion or Pet
Doggie Daycare
When vaccinated, we plan to take our puppy with us to the pet store or other dog friendly business
My puppy will visit other family homes or is pet-sat in other homes with other dogs or cats
Other pets visit inside the home (family pets, fosters, client is a pet sitter)
I'd like to take my puppy to a Dog Park
Once vaccinated we plan to take my Puppy to School/Class or Adult Obedience Training
When vaccinated, my puppy may be going to a Boarding or Grooming Facility
We plan to use a traveling groomer.
We plan to use an in-home pet sitter when we are away.
I'd Like to talk with the Groomer if she's available during my puppy's appointment
My pup will be a competitor in organized agility, hunting or herding
My puppy is a show dog
We plan to travel with my puppy this year
We plan to take our puppy hunting/hiking/fishing or camping
My puppy is likely to learn and enjoy swimming
We Feed our Pet(s) Outdoors
My puppy is in training as a working Animal : guardian, hunting, herding or rescue
My puppy is in training as a working animal: medical or emotional support/therapy
This puppy will live in an institution (such as a nursing care facility or school)
This is a foster puppy looking for a forever home
We foster other animals
I work in animal medicine or volunteer at an animal shelter
This puppy is a breeding animal
Other
Planned Kitten Activities or Occupation
My kitten will stay at home with housemates exclusively (we plan to use a pet sitter when we are away)
My kitten will visit other family homes or is pet-sat in other homes with other dogs or cats
Pets from other homes frequent our home
My kitten will visit or stay in a pet store (i.e. PetSmart window)
I'm interested in a kitten socialization class
My kitten will probably attend a boarding or grooming facility
I'd like to talk with the groomer during my visit about what she would recommend
My kitten will compete in shows
My kitten will travel with the family
We Feed our Pet(s) Outdoors
My kitten is a working animal: medical or emotional support/therapy
This kitten will live in an institution (such as a nursing care facility or school)
This is a Foster kitten
This is a companion or pet cat
We Foster other Animals
This kitten is a barn cat
This kitten will be a breeding animal
This kitten is, hopefully, a mouser
Would you like any recommendations on your pet's activities or training this year? Or to ask any questions?
Lifestyle I - Surrounding Environment
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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
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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
Other
Lifestyle Plan - Adjustments to Planning if Needed
Is there any change in the training, activities, or adjustments to diet or environment that you'd like to discuss since your prior visit with us?
Lifestyle - Exposure to New Animals Not On Record
Have you adopted any additional pets or encountered any new playmates? Have you observed any new insects or wildlife on your property?
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Next - Resources
Resources
Medication I
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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 would like this medication sent to our door via your online pharmacy https://www.highlandvet.net/patient-center/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 puppy has not been on heartworm prevention AND they are over 6 months of age
N/A My Puppy is less than 6months old
Feline Retrovirus (FLV/FIV) and Heartworm Test Status
My kitten tested negative for FIV and FLV please see recent medical history or adoption papers.
My kitten has not, to my knowledge been tested for FIV or FLV
My kitten is an FIV positive patient
My cat has tested positive for FLV
My Puppy's Anti-Parasitic Plan:
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Interceptor Plus & Bravecto 1 month Chewable Bundle (Heartworm, Hookworms, Roundworms, Whipworms, Tapeworms, Plus Fleas and All Species of Ticks- https://tinyurl.com/HVCinterceptorplus and https://tinyurl.com/HVCBravecto
Provecta Advanced - Topical - Repels and kills ticks, fleas, and mosquitos (>7wks only) - https://provectapet.com/
Simparica Trio Chewable (Heartworm, Flea, Tick, Hooks & Rounds)- https://tinyurl.com/HVCsimparicatrio
Converting to Proheart 6months at >26wks - Heartworms & Hookworms (plus Internal Parasite Assurance) https://tinyurl.com/proheart6
Converting to Bravecto 3month at >26wks - Fleas, All Ticks, Mange Mites, Ear Mites) https://tinyurl.com/HVCBravecto
Over the Counter Flea Tick Prevention
Unsure
Other
My Kitten's Parasite Prevention Plan
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Revolution for puppies and kittens - Prevents fleas, ear mites, heartworm disease, roundworms, and hookworms
Converting to Revolution Plus at >8wks of age - Fleas, Ticks, Mites, Ear Mites, Heartworms https://www.zoetispetcare.com/products/revolution-plus
Converting to Bravecto 2 Month Topical Solution at >26wks - Fleas, Ticks, Mites, Ear Mites, Heartworms https://tinyurl.com/HVCCatBravecto
Provecta II for Cats and Kittens - Fleas https://provectapet.com/
Over the Counter Flea Tick Prevention
Unsurel
Other
Resources - Current Dietary or Meal Plan At Home
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Please list all brands and types of foods or treats (over the counter, homemade, or "people food"), that the patient receives in an average day. For each food or treat, please list the amount the patient receives in the average day, 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. Kittens are often free-fed, and puppies are often fed on a nutritionally sound schedule which works according to age and to assist with housetraining: https://www.akc.org/expert-advice/health/puppy-feeding-fundamentals/
Resources - Current Dietary or Meal Plan at Home - Puppy
My Pet's Diet is currently a Purina, Hills, or Royal Canin product and I'm interested in receiving it at home for the best price 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 Purina, Hills, or Royal Canin product, and I am interested in receiving it at home for the best price via: https://tinyurl.com/HVCCatFoodCovetrus Hills at Home, or Purina Vet Direct
Resources Puppy Housetraining - Healthy Elimination & Urination
Crate Training
Baby Gates or Play Pens
Pee-pads or Paper Training
Dog Litter Pan or "Indoor Lawn"
So far my puppy's training seems successful
I'm not sure my puppy's housetraining is going well
Other
Resources Puppy Housetraining II
Puppies will usually be able to hold their bladder about one hour for every month they have been alive. High quality puppy food, and timed feeding methods help you to time elimination and bowel movements based on feeding schedule. Feel free to ask questions here or comment about any housetraining topics you'd like to discuss during your visit.
Resources - Behavioral - Chewing/Teething, Enrichment, Exercise, Work, Socialization
Puppies develop and lose baby teeth between 4-6 months of age. as they teeth they often need safe items to naturally relieve their gum pain and to relieve boredom. What sort of activities to you or your family members plan to use to engage your puppy mentally and emotionally. Would you like suggestions or do you have questions?
Resources - Microchipping, Leash Training, Travel and Home Safety Plan
Is your pet microchipped? Do you have leash training plans for your puppy? Do you know how to get a kitten used to a carrier? Have you evaluated electrical cord access or other home risks? If not or if you have questions--We can help :)
Microchipping
If my puppy or kitten is old enough, I would like to have a HomeAgain TempScan® Microchip Implanted + Registration ($42) https://www.homeagain.com/
My puppy or kitten is already microchipped - Please make sure the chip scans positively as part of our visit.
Resources - Drinking Water - Kitten
My Kitten shares a water bowl or fountain with dogs
My Kitten's water bowl or fountain is separate from my dog's 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 Kittens
I provide or plan to provide elevated "safe zones" for my kitten who lives in a multiple pet household
I do not have other pets, but plan to provide elevated resting areas for my kitten 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
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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.
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Next - Condition & History
Health Conditions and Health History
Current Apparent Attitude/Disposition
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Bright. Alert, Responsive
Quiet, But Alert, Responsive
Depressed/Lethargic, But Aware
Moribund and Listless, May or May Not be Respond Normally
Vomiting?
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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
Other
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?
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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?
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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
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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
Other
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?
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Please Select
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.
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Next
Using the chart above please rate your pet's level of itching or self grooming at this time.
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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.
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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"
Other
Regarding Your Pet's Appetite and Levels of Thirst
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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 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
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My Pet's Bowel Movements Seem Normal in Frequency for his/her age
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
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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
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My Pet's Urination Seems Normal in Frequency for his/her age
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)
Other
Changes or Abnormalities in Urinary Movements
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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.
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Next - Pain & Mobility Screen
Pain & Mobility Screen
Gait, Balance, 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
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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, Balance, Pain, or Mobility
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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.
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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
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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
Other
Concerns with Behavior or Emotional Wellness
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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 we can keep on file relative to a medical concern or just a growth photo we'd love to see it and integrate it with your patient's chart, or update their profile picture..
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Finish
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