Kitten Wellness Check-In

1

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

2

Name on the Account* This field is required.

First Name

Last Name

3

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

4

Pet's Name* This field is required.

Pet's name on file

5

Is this your kitten's first visit With Premier VetCare?* This field is required.

YESNO

6

Tell us how you got this kitten. Majority of cats are strays that pick us, as they come into our homes. We like to know where you acquired this kitten.

7

Are you positive about your kittens sex?Determining the the sex of young kittens can be a challenge some times. No worries we can help.

Yes, I am sure its male

Yes, I am sure its female

I am not sure, I need some help to figure that out.

8

When did you pick up or adopt your kitten?* This field is required.

Date you picked up the puppy.

9

Do you know your kitten's exact birth date?* This field is required.

YESNO

10

What is your kitten's Birth Date?Please provide the kitten's birth date if known, or approximate birth date if your not sure.

Puppies Birth date

11

Has your kitten had any vaccinations already?* This field is required.

YESNO

12

If you have a copy of any vaccine or health records please upload an image.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

13

Has you kitten had any recently illnesses?* This field is required.

YESNO

14

Was your kitten been at an Emergency Hospital or other practice for this illness?

YESNO

15

Please Describe the injury or illness.

16

Have you seen any worms in you kitten's stool?* This field is required.

YESNO

17

Has your kitten received any deworming medications?* This field is required.

YESNO

18

How many times has the kitten been dewormed?

Once

Twice

More than twice

I am not sure.

19

Tell us what was used to deworm your kitten if you know.

20

Have you seen any Fleas or Ticks on your * This field is required.

YESNO

21

Has the kitten been treated with any Flea and Tick preventive?* This field is required.

YESNO

22

What Flea and Tick Preventive was used if you know?If it was just a bath we like like to know that as well.

23

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

YESNO

24

Please list any mediations your kitten is currently receiving?

25

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

YESNO

26

What was that allergic reaction to?Mark all that apply

Vaccines

Antibiotic medication

Unknown Reaction

Other

27

What Vaccine do you believe the reaction was to?

Rabies

Feline Distemper

Feline Leukemia

Do not know for sure.

28

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.

29

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

31

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

YESNO

32

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

33

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

YESNO

34

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.

35

Tell us your concerns regarding your pet's appetite?

36

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

YESNO

37

Please describe the Vomiting.

38

What does your pet's fecal consistency look like.* This field is required.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

I am not sure. I have not looked.

39

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

40

Any changes in your pet's energy or activity level? * This field is required.

YESNO

41

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

42

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

YESNO

43

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

44

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

YESNO

45

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.

46

Does you kitten currently have any clear or green discharge of the eyes or nose?* This field is required.

YESNO

47

Has the eye and/ or nose been getting better or worse?

Getting BetterGetting Worse

48

When did you first notice any discharge from the eyes and/ or nose?

49

Noticed any bad breath?* This field is required.

YESNO

50

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

YESNO

51

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

YESNO

52

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.

53

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

YESNO

54

Where are they loosing hair from?

55

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

YESNO

56

Have you noticed any unusual discharge from anywhere besides the eyes or nose?* This field is required.

YESNO

57

Where is discharge coming from?

58

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.

59

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

60

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

This is a new kitten, we need a post purchase / adoption exam.

This is a new kitten, we need a post purchase / adoption exam, and wellness vaccinations if due.

Exam and Booster Wellness Vaccinations

Feline Leukemia and Feline Aids Testing ( recommended for all new kittens)

Nail Trim

Other