ECV - Preventive Exam Health History

1

Your Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Pet's Name* This field is required.

4

Species* This field is required.

5

Sex

6

Are you a new client?* This field is required.

YESNO

7

Have you completed the new patient form?* This field is required.

YESNO

8

Have we seen this pet before?* This field is required.

YESNO

9

Please fill out the New Patient form. When done, click "next".

10

Have you noticed any issues/problems/concerns with {petsName129}?* This field is required.

11

What type of food are you feeding {petsName129}?* This field is required.

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How much do you feed {petsName129}?* This field is required.

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How often do you feed {petsName129}?* This field is required.

14

Have you noticed any changes in your pet's eating habits?* This field is required.

15

Do you give {petsName129} heartworm prevention?* This field is required.

YESNO

16

What specific heartworm product do you give?

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When was the last dose given?

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Do you administer heartworm year round? * This field is required.

YESNO

19

Do you give {petsName129} flea/tick prevention?* This field is required.

YESNO

20

What specific flea/tick product do you give?

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When was the last dose given?

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Do you administer flea/tick prevention year round?* This field is required.

YESNO

23

Have you seen any ticks on {petsName129}?* This field is required.

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Have you seen any fleas on your {petsName129}?* This field is required.

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if you have other pets, have you seen any fleas on them?* This field is required.

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Will {petsName129} stay in a boarding facility?* This field is required.

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Will {petsName129} visit a pet groomer?* This field is required.

28

Will {petsName129} visit public places (pet store, dog park, competitions, 4H)?* This field is required.

29

What percentage of time does your {petsName129} spend outside?

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Is {petsName129} taking any medications or supplements? * This field is required.

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What medications, strength and frequency?

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What is {petsName129}'s water source?* This field is required.

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How often is it changed?* This field is required.

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Have you noticed any changes in {petsName129}'s water consumption?* This field is required.

35

What additional concerns or questions do you have?

36

East Central Veterinarians offers wellness plans to provide your pet with the recommended annual veterinary services necessary to keep your pet healthy and to detect health changes early. Every East Central Wellness Plan can be customized for the specific, evolving needs of {petsName129}.

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Are you interested in a wellness plan?

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East Central Veterinarians tailoring {petsName129}’s vaccine protocol to meet their lifestyle. All {species} should receive the DAPP distemper combination with leptospirosis and rabies vaccines. The following questions can help us to determine which additional vaccines we should consider.

39

East Central Veterinarians tailoring {petsName129}’s vaccine protocol to meet their lifestyle. All ferrets should receive the distemper combo series and rabies vaccines.

40

{petsName129} could be exposed to Influenza and Bordetella:

Goes to a groomer, obedience classes, agility, flyball, or dog shows
Is boarded or goes to daycare
Goes to dog parks

41

Do you want to start/continue the Bordetella vaccine? Bordetella Vaccine (“kennel cough”) – $32.50, given once a year

42

Do you want to start/continue the influenze vaccine? Canine Influenza Vaccine (bivalent) - $45.20 per dose, boostered 3-4 weeks after the first vaccine, then once a year.

43

{petsName129} could be exposed to Lyme disease if he or she goes to areas where Lyme disease is common (north central MN, northeast MN, and the western 2/3 of Wisconsin, spends time in tall, grassy areas, cabins, camping or hunting, or has had ticks (even with tick control). Lyme Vaccine is $47.55 per dose, and is boostered 3-4 weeks after the first vaccine, then once per year. Do you want to start/continue the Lyme vaccine?

44

East Central Veterinarians tailoring {petsName129}’s vaccine protocol to meet their lifestyle. All {species} should receive the RCP distemper combination and rabies vaccines.

{petsName129} could be exposed to Feline Leukemia if:

Lives with another cat who has Feline Leukemia
Lives outside (full-time or part-time)
Escapes outside

45

Do you want to start the Feline Leukemia vaccine? Feline Leukemia Virus (FeLV) Vaccine - $41.75 per dose, boostered 3-4 weeks after the first vaccine, then once a year.

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East Central Veterinarians tailoring {petsName129}'s vaccine protocol to meet their lifestyle. All {species} should receive the rabies vaccines.

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Do you want {petsName129} to have the rabies vaccine?

48

Rabbit hemorrhagic disease (RHDV2) is a fatal disease and is highly contagious and, unlike other rabbit hemorrhagic disease viruses, it affects both domestic and wild rabbits. It was first found in Minnesota in February 2020. East Central Veterinarians carries a vaccine that has been given emergency use authorization by the USDA. Do you want to start the RHDV2 vaccine? RHDV2 Vaccine is - $29.10 per dose, boostered 3-4 weeks after the first vaccine, then once a year.

49

East Central Veterinarians recommends Revolution Plus for all cats and kittens, this topical medication that protects your cat against six types of common parasites: heartworm disease, adult hookworm, adult roundworm, ear mites, fleas, and ticks. This medication needs to be applied to the skin at the base of your cat’s neck every month. If your cat is on a wellness plan, heartworm prevention can be added to your plan.

50

Heartworm prevention is critical to the health of dogs in Minnesota. East Central Veterinarians provides two options for heartworm prevention. If your dog is on a wellness plan, heartworm prevention is already included on your plan.

1) Interceptor Plus is a broad spectrum heartworm and internal parasite medication. It is a chicken-flavored chew given each month to protect your dog against five types of common (and potentially deadly) parasites: Heartworm disease, Adult hookworm, Adult roundworm, adult whipworm, and adult tapeworm.

2) Proheart 12 is a convenient once-a-year injection to prevent heartworm disease and to treat adult hookworms in dogs.

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Birds

Our veterinarians find some additional background information on {petsName129} can be helpful for their appointment:

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Length of time owned? * This field is required.

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Where was {petsName129} acquired?

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Any other birds?* This field is required.

YESNO

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Are they housed together or singly?

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Any other pets?

YESNO

57

How often is {petsName129} handled?* This field is required.

58

Is {petsName129} ever taken outside?* This field is required.

YESNO

59

When was the last molt? Any trouble?* This field is required.

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For the next question, please take note of the current state of your bird's droppings.

61

Fecal consistency?* This field is required.

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Have you noticed any changes in your pet's bowel movements?* This field is required.

63

What type of enclosure does {petsName129} have?* This field is required.

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Size of {petsName129}'s enclosure?* This field is required.

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Where is {petsName129}'s enclosure located in your home?* This field is required.

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Type of cage substrate?* This field is required.

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How frequently is it cleaned and what it used for cleaning?* This field is required.

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What types of toys/perches are offered?* This field is required.

70

Have you noticed any changes in your pet's eating habits?* This field is required.

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What brand and amount fed/frequency?

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What brand and amount fed/frequency?

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What brand and amount fed/frequency?

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What brand and amount fed/frequency?

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Small Mammals

Our veterinarians find some additional info helpful for small mammal appointments.

Background Information on {petsName129}:

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Length of time owned?* This field is required.

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Where was {petsName129} acquired?* This field is required.

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Any other small mammals?* This field is required.

YESNO

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Are they housed together or singly? * This field is required.

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Any other pets?

YESNO

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How often is {petsName129} handled?* This field is required.

82

Is {petsName129} ever taken outside?* This field is required.

YESNO

83

For the next question, please take note of your rabbit's droppings.

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Fecal consistency?* This field is required.

85

Have you noticed any changes in your pet's bowel movements?* This field is required.

86

What type of enclosure does {petsName129} have?* This field is required.

87

Size of {petsName129}'s enclosure?* This field is required.

88

Where is {petsName129} 's enclosure located in your home?* This field is required.

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Type of cage substrate (substrate is the material in the bottom of the cage)?* This field is required.

90

How frequently is it cleaned and what is used for cleaning?* This field is required.

91

What types of cage furniture and chew toys are available?* This field is required.

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Type of food offered?* This field is required.

Pellets

Hay

Other

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Have you noticed any changes in your pet's eating habits? * This field is required.

94

What brand and amount fed/frequency?

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What brand and amount fed/frequency?

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REPTILES

Background Information on {petsName129}:

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Length of time owned?* This field is required.

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Where was {petsName129} acquired?* This field is required.

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Any other reptiles?* This field is required.

YESNO

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Are they housed together or singly?* This field is required.

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Any other pets?* This field is required.

YESNO

102

How often is {petsName129} handled?* This field is required.

103

Is {petsName129} ever taken outside?* This field is required.

YESNO

104

When was the last shed? Any trouble?* This field is required.

105

Fecal consistency?* This field is required.

106

Have you noticed any changes in your pet's bowel movements?* This field is required.

107

What type of enclosure does {petsName129} have?* This field is required.

108

Size of {petsName129}'s enclosure?* This field is required.

109

Where is {petsName129}'s enclosure located in your home?* This field is required.

110

Type of cage substrate?* This field is required.

111

How frequently is it cleaned and what is used for cleaning?* This field is required.

112

Type of lighting and what light cycle is used?* This field is required.

113

What heat sources are used?* This field is required.

114

What are the minimum and maximum temperatures in the enclosure?* This field is required.

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Humidity level?* This field is required.

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Type of food offered?* This field is required.

117

Frequency and amount fed?* This field is required.

118

When was the last feeding?* This field is required.

119

Have you noticed any changes in your {petsName129}'s eating habits?* This field is required.

120

We look forward to seeing {petsName129} soon. In preparation for your upcoming appointment, we ask:

Please arrive 10 minutes prior to your scheduled time with the doctor to ensure your check-in is complete.
When you arrive, please come inside to check-in for your pet’s appointment.
If your pet is anxious or more comfortable remaining in the vehicle until we have an exam room ready please call the phone number on the sign. If the phone line is busy we are checking in another client, please wait a minute and try again.
If you are more than 10 minutes late to your scheduled appointment we will need to reschedule the appointment to ensure other clients are seen in a timely manner.
If you need to cancel or reschedule your appointment, please contact us at least 48 hours before your scheduled appointment.
All pets must be on a secure leash or in a carrier.

Thanks,

East Central Veterinarians Team

BirdsOur veterinarians find some additional background information on {petsName129} can be helpful for their appointment:

We look forward to seeing {petsName129} soon. In preparation for your upcoming appointment, we ask:

Birds

Our veterinarians find some additional background information on {petsName129} can be helpful for their appointment: