Senior Wellness Check-In

Senior pets, those over 5-7 years old, have more health concerns that develop. To help screen for some of the more common disorders of please complete the following questionarie regarding your pet's health. This information is used by our team and docotors to understand your pet's health care needs better.

By completing this form prior to your visit we can speed up your pet's check in process.

www.premier.vet

13197 Old Nashville Hwy, Smyrna, TN

615-459-0802

Name on the Account* This field is required.

First Name

Last Name

Phone Number* This field is required.Used to verify your client account.

Pet's Name* This field is required.

Pet's name on file

Pet's Species

Canine

Feline

Any recent injury or illness? * This field is required.

YESNO

Was you pet seen at an Emergency Hospital or other practice for this illness?

YESNO

Please Describe the injury or illness.

Is your pet getting a monthly Heartworm & Internal parasite preventive as recommended?* This field is required.

YESNO

How often does your pet get a dose of Heartworm & Internal parasite Preventive?

Every month

Occasional I forget, but most months.

I forget alot, so maybe every few months.

Not regularly.

I am not sure.

What Heartworm & Intestinal preventive product are you using?

Is the pet on Flea and Tick preventive? * This field is required.

YESNO

How often is your pet getting a Flea and Tick Preventive?

Monthly

Every few months

Spring months

Summer months

Fall months

Only When I see them itching

Only when I see Fleas or Ticks

Other

What Flea and Tick Preventive are you currently using?

Is the pet currently on any medications other than preventives? * This field is required.

YESNO

Please list any mediations your pet is currently receiving?

Has your pet had an allergic reaction to any vaccines, or drugs/medications in the past?* This field is required.

YESNO

What was that allergic reaction to?Mark all that apply

Vaccines

Antibiotic medication

ProHeart Injection

NSAID / Pain medicaiton

Unknown Reaction

Other

What Vaccine do you believe the reaction was to?

Rabies

Lepto

Canine Distemper

Do not know for sure.

What Vaccine do you believe the reaction was to?

Rabies

Feline Distemper

Feline Leukemia

Do not know for sure.

Pre-visit Benadryl (Diphenhydramine)

If your pet has had prior allegic reactions to vaccines we can reduce the risk of reactions if you give a dose of benedrly prior to your visit. If you can not do so we can give an ingection at the begingin of the visit. ( additional cost do apply for injections )

Please give your pet a dose of Benadryl or a generic ( Diphenhydramine ) 1-2 hours prior to the appointment time. The dose is 1 mg per pound. The tablet size is typicaly 25 mg.

It must be plan Diphenhydramine, be sure there are no other drugs in the tablets.

0-5 lbs give 1/4 of a tablet

6-12 lbs give 1/2 of a tablet

12-18 lbs give 3/4 of a tablet ( 1/4 and 1/2 of a tablet)

19-25 lbs give 1 full tablet

26-30 lbs give 1 & 1/4 tablets

31-37 lbs give 1 & 1/2 tablets

38-44 lbs Give 1 & 3/4 tablets

44-50 lbs Give 2 tablets

Pet's over 50 lbs rarely have reactions, please email or call if you need the dose.

If any questions if you should or how much bendrly (Diphenhydramine) to give your pet prior to vaccines please email us at info@premier.vet

Screen shot this info for reference if you needed.

What was the name of the medication they had a reaction to, if you recall?

What type of reaction did they have?

Swelling of face.

Swelling or pain at injection site.

Generalized pain

Vomiting

Diarrhea

Other

Does your dog need any refills for Parasite Preventives or other medications today?* This field is required.

YESNO

Does your cat need any refills for Parasite Preventives or other medications today?* This field is required.

YESNO

We ask that you request any refills for prescritions filled at pharmacies outside our practice or our online store be requested at the time of your visit.

Written Prescriptions are Provided Only at Time of Exam.

We respect the right of our clients to get their pet's medications from the pharmacy of their choice. Unfortunately, due to the high number of request by online pharmacies that are inappropriate and consume a large amount of our staff time we will not review or honor request out side of a exam and/or consult at no charge. If you are in need of any written prescriptions please ask us and we be glad to provide them during your pets visit. We can not replace lost, or misplaced prescriptions. We will not write new prescriptions if you choose to change pharmacies. In the event you must change pharmacies you will need to contact the original pharmacy to have your prescription transferred. We are sorry for any inconvenience this policy creates, but it is necessary to ensure excessive prescriptions are not acquired and to manage our staffs time in caring for the pets we see daily.

To process these request, out side of an exam appointment, requires staff to review your pets records, have a doctor review and approve the request and to prepare the written prescription. To partial recover the cost of those request there is a $25 fee for written scripts requested outside of an exam appointment. This fee covers record review and our standard prescription fees.

You can review our complete Prescription Policy at the link below.

Premier VetCare Prescrition Policy

What In-House Parasite Preventives do you need refilled?Choose all that apply.

Interceptor Plus

Proheart 6

Proheart 12

Simparica Trio

Simparica

Revolution ( Small dogs & Cats )

What In-House Parasite Preventives do you need refilled?Choose all that apply.

Revolution Plus

What Parasite Preventives do you need a written prescription for?Please list all medications you need refilled. There are additional fees to refill medications outside of an visit.

What other medications do you need refilled?Please list all medications you need refilled. There are additional fees to refill medications outside of an visit.

Any recent changes in diet, or do you have any questions regarding your pets diet? * This field is required.

YESNO

What changes did you make, or what questions you have about you pet's diet?

Has your pet been eating normally? * This field is required.

YESNO

Tell us about you pets eating habits.

Pet seems to always be hungry, but that's normal.

Pet leaves food in the bowl.

Pet is a picky eater.

Pet has developed a really ravenous appetite, stealing food from the counter, or plates when they can.

Tell us your concerns regarding your pet's appetite?

Has your pet had any vomiting recently?* This field is required.

YESNO

Please describe the Vomiting.

Tell us about your pets water consumption.* This field is required.

It has not changed

Been drinking less water.

Been drinking a little more water than normal.

Been drinking alot more water than normal.

Drinks so much water we can not seem to keep the water bowl full.

Other

Any changes in your pet's energy or activity level?

YESNO

Describe what changes in your pet's activity your concerned about.

Have you heard any coughing that is new?* This field is required.

YESNO

How many times a day does your pet cough, and when did it start?

Has your pet had any diarrhea or loose stool recently?* This field is required.

YESNO

What does your pet's fecal consistency look like.Fecal consistency is primarily a function of moisture in stool and can be used to identify changes in colon health and other problems. In a healthy dog or cat, stools ideally should be firm but not hard, pliable, segmented and easy to pick up (Score 2).

1 : Very hard and dry/ Often expelled as individual pellets/ Requires much effort to expel from the body/ Leaves no surface residue when picked up

2 : Firm, but not hard/ Segmented appearance/ Leaves little or no surface residue when picked up

3 : Log shaped; moist surface/ Little or no visible segmentation/ Leaves surface residue, but holds form when picked up

4 : Very moist and soggy/ Log shaped/ Leaves surface residue and loses form when picked up

5 : Very moist, but has a distinct shape/ Present in piles rather than logs/ Leaves surface residue and loses form when picked up

6 : Has texture, but no defined shape/ Present as piles or spots/ Leaves surface residue when picked up

7 : Watery/ No texture/ Present in flat puddles

Has your pet been doing any sneezing?* This field is required.

YESNO

How often does your pet sneeze?

Occasionally

At least once a week.

At least once a day.

Several times in a day.

The sneeze a lot, and is concerning.

Any new Lumps or Bumps your concerned about?* This field is required.

YESNO

Where are these lumps or bumps at?

Noticed any bad breath?* This field is required.

YESNO

Have you noticed your pet shaking their head or scratching at their ears?* This field is required.

YESNO

Is your pet scratching or licking excessively anywhere?* This field is required.

YESNO

Describe the Itching or licking. Please include how severe it is, how long its been going on, and where the itch or lick the most.

Does your pet paw at their lips or face, rub their face along the carpet or furniture?* This field is required.

YESNO

Have you noticed any hair loss?* This field is required.

YESNO

Where are they loosing hair from?

Is your pet scooting their rear along the floor/ or licking the rear more than normal?

YESNO

Have you noticed any unusual discharge? * This field is required.

YESNO

Where is discharge coming from?

Have you noticed any new lameness/ or like to discuss a old lameness? * This field is required.

YESNO

Is your pet having any difficulty rising?

YESNO

Is your pet having any difficulty climbing stairs, or on to furniture?

YESNO

What leg is your pet having trouble with?Mark all that apply.

Lameness is new.

Lameness is old, they have history of arthritis

Right front leg

Left front leg

Right Rear leg

Left Rear leg

General seems slow to rise

Lameness is worse in the morning, but gets better as day goes on.

Not very lame in the morning, but gets worse as the day goes on.

Lameness is worse for a day or more after a lot of exercise.

Have you noticed any new behavioral changes you are concerned about?

YESNO

Tell us about those behavioral changes you are concerned about?

Do you wish to be present while the pet is examined or vaccinated?* This field is required.

Yes, I like to be present at time of exam and vaccines.

No, I do better if I am not around when my pet is getting injections.

No, my pet does better if I am not close by.

Does your pet have any new medical conditions?

Has your dog been diagnosed with any of the following problems?Mark all that apply

Arthritis

Dental Disease

Cancer

Heart Disease / Failure

Kidney Disease / Failure

Liver Disease/ Failure

Diabetes

Cushing's Disease

Addison's Disease

Hypothyroid Disease

Glaucoma

Blindness

Hearing Loss

Urinary Stones or Blockages

Autoimmune Disease

Has your cat been diagnosed with any of the following problems?Mark all that apply

Arthritis

Dental Disease

Cancer

Heart Disease / Failure

High Blood Pressure

Kidney Disease / Failure

Liver Disease/ Failure

Diabetes

Hyperthyroid Disease

Glaucoma

Blindness

Hearing Loss

Urinary Stones or Blockage

Autoimmune disease

Is there anything else we need to know about or other questions for our team or the doctor?

What Services does your pet need?* This field is required.We will review our pet's records and make appropriate recommendations as well.

Premier Pet Senior Wellness Package- All needed vaccines, Senior Blood work, Screening Radiographs, and yearly internal parasite testing.

Premier Pet Adult Wellness Package- All Needed Vaccines and parasite testing.

Exam with Core Vaccines, No parasite or other senior pet screening test.

Vaccines I need for boarding, grooming, or pet daycare.

I only need a Rabies Vaccine, no Exam ( Your currently scheduled for an exam with one of our doctors. If this is all you need please call us to reschedule as a Technician / Assistant Visit. )

Just a medical progress exam and Heartworm testing for a prescription of heartworm and internal parasite prevention.

Just need Exam today for medication refills.

Medical progress exam and blood work for medication refills.

My pet needs an exam and surgery consultation.

Anal Sac Expression

Other

Alert!

You have made an appointment for Senior Wellness visit for your pet. You indicated you only wanted the minimal legally required Rabies Vaccination.

Rabies Only vaccines visits are performed by our trained technichan and assistant team. You will not have an exam with a doctor if this is all you need or want.

If you like to have your pet examined by one of our doctors please select the "Exam with Core Vaccine" option.

Please call us or email us if you have any questions, concerns or need to update your appointment type. To server all the clients that need an appointment time with a docotor, if we do not hear from you the appoinment will be moved to a Tech/ Assistant appointment, and you will not have an exam appointment time with one of our doctors.

Senior Wellness Check-In