Puppy 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 Puppy's First Visit With Premier VetCare?* This field is required.

YESNO

6

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

Date you picked up the puppy.

7

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

YESNO

8

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

Puppies Birth date

9

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

YESNO

10

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

11

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

YESNO

12

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

YESNO

13

Please Describe the injury or illness.

14

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

YESNO

15

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

YESNO

16

How many times has the puppy been dewormed?

Once

Twice

More than twice

I am not sure.

17

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

18

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

YESNO

19

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

YESNO

20

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

21

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

YESNO

22

Please list any mediations your pet is currently receiving?

23

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

YESNO

24

What was that allergic reaction to?Mark all that apply

Vaccines

Antibiotic medication

Unknown Reaction

Other

25

What Vaccine do you believe the reaction was to?

Rabies

Lepto

Canine Distemper

Do not know for sure.

26

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.

27

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

29

What are you currently feeding your puppy?* This field is required.

30

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

YESNO

31

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

32

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

YESNO

33

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.

I have had to hand feed the puppy.

Other

34

Tell us your concerns regarding your pet's appetite?

35

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

YESNO

36

Please describe the Vomiting.

37

What does your puppy'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 do not know I have not looked at it.

38

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

39

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

YESNO

40

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

41

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

YESNO

42

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

43

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

YESNO

44

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.

45

Noticed any bad breath?* This field is required.

YESNO

46

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

YESNO

47

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

YESNO

48

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.

49

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

YESNO

50

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

YESNO

51

Where are they loosing hair from?

52

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

YESNO

53

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

YESNO

54

Where is discharge coming from?

55

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.

56

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

57

Are currently or planning to Crate Train Your Puppy?

YESNO

58

Crate Training

We highly recommend that all puppies are crate trained from the start, but no dog is to old to start the process.

Crate training is the first step in helping keep your puppy safe, and has been proven to reduce the chances of your pet developing behavior and anxiety issues as they get older.

Crate trained puppies will often be eeasier to house train, and less likely to chew on, or get into things that could be dangerous to them.

Untill a puppy reaches a more mature age and is well trained they should never be left unconfined when no one is close by watching them. By placing your puppy in a crate when you can not watch them your providing them a safe place to rest and keep them out of trouble.

Crating in not cruel to pets, it gives them a space of their own they can safely rest and be left alone if they wish.

For more information on crate training and house training you can Click Here.

59

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 puppy, we need a post purchase / adoption exam.

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

Puppy Exam and Wellness Vaccines

Nail Trim

Other