Recheck Consultation Questionnaire

Recheck Consultation

Recheck consultations take place in person or virtually by Zoom. Please note that medication changes can not be made outside of a recheck consultation. If a medication change is requested (dose or actual prescription then a recheck consultation with Dr. Nicholson is required. This recheck serves to discuss your pet's behaviour, your concerns, the reason for this request, and the appropriate steps to ensure a safe adjustment in the treatment plan.
Owner Information
First Name:
Last Name:
Patient Information
Pet's Name:
Current Weight (kg):
Date Weighed

MonthDayYear
Date
Presenting behaviour(s) of concern:
1. Why are you seeking a recheck consultation?

0/200
Current Medications & Supplements

Please list all medications that your pet is currently taking, including medications not intended for behaviour concerns (i.e. - Reconcile 8mg: 1 tablet every 24 hours).
1.
2.
3.
4.
Do you require refills of any medication? (please check with your pharmacy or primary care veterinarian before submitting this form as refills will not be given outside of a recheck appointment)
Where would you like your prescription sent?
If pharmacy, name and address.
Reviewing your Pet's History:
1. Have you noted any improvements?
If yes, please describe.

0/200
2. Has anything remained the same?
If yes, please describe.

0/200
3. Has anything worsened?
If yes, please describe.

0/200
4. Have you implemented any behaviour modification exercises/measures?
If yes, please describe what changes were made and the impact it made.

0/300
5. Are there any changes or behaviour modification exercises that we have previously discussed that you would like to implement but have not been able to, or have not been successful? (i.e. too difficult, time constraint, ect.)
If yes, please describe.

0/300
Additional Information
1. What are your goals for this recheck consultation?
2. Is there any other information you would like to add or mention prior to the recheck consultation?

0/300
Thank you for choosing OVBS, we look forward to meeting with you!
This is a fill in the blanks field. Please add appropriate blank fields and text.
Should be Empty:

Recheck Consultation

Owner Information

Patient Information

Presenting behaviour(s) of concern:

Current Medications & Supplements

Reviewing your Pet's History:

Additional Information