GI EXAMINATION - Virtual Check-In & Patient History
The following health history/risk assessment is a comprehensive look at your pets most recent GI health history at home. If we are performing a complete exam focused on gastrointestinal health or condition this focused history will be helpful in identifying your pet's most pressing concerns. It will take about 10-15 minutes to thoughtfully complete, and is best completed by your pet's primary caregiver. Completing this intake to the best of your ability should help us ensure accuracy and efficiency when arriving at a patient treatment plan
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
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
Primary goal for today's visit
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List your understanding of the purpose of this appointment or visit, and/or any questions you have about the appointment.
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Next - General Information
GENERAL INFORMATION
Patient Species
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Canine (Dog)
Feline (Cat)
Age of Patient - Estimate Ok
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Indicate above how old your pet may be in terms of weeks, months, or years
Lifestyle
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Indoor Exclusively (uses litter pan or pee-pad to eliminate)
Indoor/Lanai
Indoor/Outdoor to Eliminate or Exercise
Outdoor Mostly or Exclusively
Date or Year of Most Recent Parvovirus Vaccine or Distemper/Parvo Combo (ie DHLPP or DA2PP) Vaccine if known
Date or Year of Most Recent Panleukopenia Vaccine or "Feline Distemper" Combo (ie FVRCP FCP etc) if known
Canine Activities or Occupation
Pets from Other Houses Visited our home within the last 30 days
My pet has attended a Boarding or Grooming Facility last 30 days
My pet has traveled with the Family or visited a public environment (pet store, doggie day care) in last 30 days
My pet Hunts/Hikes/Goes Fishing or Camping
We Feed our Pet(s) Outdoors
My Dog is a Working Animal : Farm, Guardian, Hunting, Herding or Search/Rescue
This is a Foster Animal
We Foster other Animals
My pet swims or drinks from puddles/standing water
Other
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
Has visited the Pet Store (i.e. PetSmart Window) last 30 days
Goes to Kitten Socialization Class
Has attended a Boarding or Grooming Facilities last 30 days
Competes in Shows
Traveled with the Family within last 30 days
We Feed our Pet(s) Outdoors
This is a Foster Animal
We Foster other Animals
Barn Cat
Lifestyle III - Protozoal Disease Risk
There is no body of water (large or small) within twenty feet of my home and my pet will not have had contact with any body of water or puddles this past year (ie has been indoor only for a year)
My pet may have contact sometimes with a body of standing water near my home or may have had a drink from standing water this year (giardia/coccidia risk)
My pet is a foster pet or newly adopted as a stray this year, and its history is unknown
Lifestyle II - Housemates and Animal Neighbors
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Other pets - Dog(s)
Other pets - Cat(s)
Livestock on Property - No direct Interaction
LIvestock on Property - Minimal or Moderate Interaction
Family Feeds Feral Cats or Stray Animals
Wild Canines (Coyotes or Foxes)
Raccoons in yard or on property
None or N/A
If Patient Has Been Around Another Animal Exhibiting Similar Signs/Condition Please Describe
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Next - Resources
Resources
Vitamins, Supplements, Over-the-Counter Remedies or Medications
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My Pet Does Not Take Vitamins, Supplements, nor OTC Medications
My Pet Takes Vitamins, Supplements or OTC Medications
My Pet Takes Probiotics Routinely
My Pet Takes Probiotics Sometimes
My Pet Takes no Prescription Medications
My Pet Takes Prescription Medications (other than routine vaccines and preventatives (hw/flea/tick etc)
My Pet has Trouble Taking Certain Medications and I Need Advice
If Possible I Would Like Chronic Medications Sent To Me https://highlandvet.vetsfirstchoice.com/
Vitamins, Supplements, Over-the-Counter Remedies or Medications II
Please list all OTCs, medications, preventatives, vitamins or nutritional/herbal supplements or remedies that your pet takes at home. Include probiotics/"medicinal foods" and brands
My Dog's Heartworm Prevention of Choice is:
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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
Other
My Dog's External Parasite Prevention (Flea/Tick Etc) of Choice is:
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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
Other
My Cat's Parasite Prevention (Flea/Tick, Heartworm, Intestinal Parasites or Ear Mites Etc) of Choice is:
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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 or Kitten has had Profender this month
My Cat is not on any parasite prevention, and hasn't had any prescription treatment this month
Other
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
Resources - Current Dietary or Meal Plan At Home
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Please list ALL types of foods or occasional 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 - Describe Most Recent Successful Meal
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Include food, date, time, and amount eaten.
Access to other food or garbage?
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If yes, please include, date, time, and amount eaten.
Any toys or other non food objects pet may have consumed? Pieces Observed? Pieces or Objects Missing?
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If yes, please include, date, time, and amount eaten.
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 one water fountain or one water bowl for more than three cats
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.
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Next - Condition & History
Health Condition and GI Signs
Please select all that apply to the best of your knowledge
My Pet has had a fecal flotation exam in the last month
My Pet has had a fecal ova and parasite exam by centrifugation within the last month
My pet has had a Giardia Test within the last month
Other
Prior Known GI Illness(es) or Abdominal Surgery(ies) (except spays)
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Please list any GI 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
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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"
Allergy History as Diagnosed by a Veterinarian - Select all that apply
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No Known Allergies
Atopy (inhaled-Seasonal or Otherwise)
Flea Allergy
Food Allergy
Vaccine Reactivity
Patient Takes Immunotherapy or has An Allergy Plan
Other
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
Does Pet Have a History of Chronic Regurgitation After Eating?
Does vomiting occur in relationship to eating?
Does pet retch or have abdominal heaving with vomiting?
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)
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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"
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'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
Have the patient's bowel movements been witnessed by owner? How Long since the owner or caregiver has observed a patient bowel movement?
Please also indicated if the owner or primary caregiver typically witnesses all bowel movements to keep track.
Regarding Your Pet's Bowel Movements
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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
Foreign Material Present In Stool
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)
You Indicated that Your Pet Has had Diarrhea on an Acute or Chronic Basis - Please select all that apply
Regular Color
Liquid/Watery
Mucoid
Black/"Tarry"
Undigested Food In Diarrhea
Small Volume/Frequent Movement
Bloody or Blood Tinged
Large Volume/Regular Frequency
Greyish or Pale
Green Color
Yellow Color
Very soft but there is shape
Worms that are shaped like grains of rice (tapeworm segments)
Worms that are long and flat (tapworms)
Worms shaped like spaghetti (roundworms)
Very soft, completely unformed
Other
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
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Next - Patient Behavior and 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
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
Other
Concerns with Behavior or Emotional Wellness
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If 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
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