Recheck Questionnaire
Date of appointment
*
/
Month
/
Day
Year
Date
Time of Appointment
*
Hour Minutes
AM
PM
AM/PM Option
Pet's name
*
Age of Pet
*
Owner Name (First and Last):
*
Preferred Phone Number:
*
Format: (000) 000-0000.
Email
*
example@example.com
Current Veterinarian Information:
Veterinarian Seen By Your Pet:
*
Veterinary Hospital/Clinic Name
*
Veterinary Hospital/Clinic Email:
*
What are your goals for this recheck consultation? Please be specific:
*
BEHAVIORAL CONCERNS
Please list your pet's pre-existing issues and please note if they are worse since your last visit.
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Rows
Pre-Existing Problem Description
WORSE? (Yes/No)
Pre-existing problem #1
Pre-existing problem #2
Pre-existing problem #3
Pre-existing problem #4
Pre-existing problem #5
For pre-existing issues, please rate the improvement in intensity. There should only be 1 response in each row.
*
Rows
Less than 25% Improvement
25%-50% Improvement
50%-75% Improvement
70%-90% Improvement
Pre-Existing Problem #1
Pre-Existing Problem #2
Pre-Existing Problem #3
Pre-Existing Problem #4
Pre-Existing Problem #5
For pre-existing issues, please rate the improvement in frequency. There should only be 1 response in each row.
*
Rows
Less than 25% Improvement
25%-50% Improvement
50%-75% Improvement
70%-90% Improvement
Pre-Existing Problem #1
Pre-Existing Problem #2
Pre-Existing Problem #3
Pre-Existing Problem #4
Pre-Existing Problem #5
Please list any new issues since your last visit and the date they began.
Rows
What Is The New Problem
Date
New Problem #1
New Problem #2
New Problem #3
New Problem #4
New Problem #5
For each new problem, please note the severity of the problem. There should only be 1 response on each row.
Rows
Not Serious
Fairly Serious
Very Serious
New Problem #1
New Problem #2
New Problem #3
New Problem #4
New Problem #5
Please give us detailed description(s) of recent representative events of current problems including the date(s) in which they occurred.
INCIDENT #1
*
Date
*
-
Month
-
Day
Year
Date
INCIDENT #2
Date
-
Month
-
Day
Year
Date
INCIDENT #3
Date
-
Month
-
Day
Year
Date
CHANGES TO HOUSEHOLD: Please tell us if there have been any changes in your household since your last appointment. If any of these are upcoming, please explain in details section
*
Rows
Y (YES)
N (NO)
Details
Arrival of new household member (please list name)
Departure or death of a household member (please list name)
Moved to a new home
Schedule change (gained/lost job, school, etc)
Pet added (list name and information)
Death or relinquishment of other pet (list name and information)
Other (please explain)
Behavior Medication
Please complete the table below regarding your pet's current medications, including dosages, frequency and if there are any side effects.
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Rows
Name
Dose (mg strength)
Frequency (How often you give it)
Side Effects (if any)
Medication #1
Medication #2
Medication #3
Medication #4
Please complete the table below regarding the response to your pets medications:
*
Rows
Worse Response
Less than 25% Better
25%-50% Better
50%-75% Better
70%-95% Better
Medication #1
Medication #2
Medication #3
Medication #4
Medical History
Please list any newly diagnosed medical problems and how they were treated:
Rows
Diagnosis Name
Date Diagnosed
Treatment (Including medications & Dosage)
Outcome
Diagnosis #1
Diagnosis #2
Diagnosis #3
Diagnosis #4
Diagnosis #5
Bite History
Has your pet bitten since your last visit?
*
2. Please list the number of bites that broke skin or type n/a
*
3. Please list the number of bites reported to public health authorities, and to whom: (i.e. local authorities, hospital, humane society, etc.):
Current Status
Have you recently considered finding another home for this pet?
*
YES
NO
Have you recently considered euthanasia (putting your pet to sleep)?
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YES
NO
What else would you like us to know about your pet and his/her current situation?
*
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