Request A Progress Evaluation

Progress Evaluation or Re-evaluation with Dr Shana

Requesting an appointment is easy! Simply fill out the form below and you will be contacted. Please note completing this form does not confirm your appointment.
Please complete one form for each dog

Each dog has their own unique answers so we require 1 form per pet
This form is only to be used for scheduling Progress Evaluations with Dr. Shana.

Please do not use this form to request medications, an appointment with a different department (Primary Care, Speciality Surgery), phone calls, or for general questions.
Please complete the forms in their entirety

Please list your dog's pre-existing behavioral concerns and their medications fully. While it may not make sense as we have it listed in their chart, it does serve a purpose and we request your cooperation.
Name*

First NameLast Name
Has your address changed recently? We want to keep our records up to date.*

Yes, my address has changed recentlyNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Pet's Name*
What type of progress evaluation are you looking to schedule*

Routine Progress EvaluationMy pet is having problems
What are your goals for this appointment? Please be specific.*

BEHAVIORAL CONCERNS: Please list your pet’s current issues and indicate whether they are pre-existing or new since your last visit. For pre-existing issues, please note what changes there have been. For new issues, please note when the behavior started and the severity of the problem.*

	Pre-Existing Problem	Worse	% of Improvement in Intensity (ex <25%, 25%-50%, %0%-75%, >75%	% of Improvement in Frequency (ex <25%, 25%-50%, %0%-75%, >75%
Problem 1
Problem 2
Problem 3
Problem 4
Problem 5

New Problems

	List Problem	Date Began	Not Serious	Fairly Serious	Very Serious
Problem 1
Problem 2
Problem 3
Problem 4
Problem 5

Please give us detailed description(s) of recent representative events of each current problem. Include the location, dog’s body postures, any people present, any triggers, your reaction, and the outcome.
Date and Incident #1
Date and Incident #2
Date and Incident #3
Date and Incident #4

CHANGES TO HOUSEHOLD*

	Y/N	Details
Arrival of new household member (please list name)
Is anyone in the household pregnant or adopting a child?
Departure or death of a household member (please list name)
Moved to 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)

Have there been any other changes to your household besides what is listed above?*

YesNo
If yes, please explain

BEHAVIOR MEDICATIONS: Please complete the table below in regard to your pet’s current medications, dosages, and apparent effectiveness.*

	MED NAME	DOSE (the mg strength)	QUANTITY(how many tabs/caps per dose)	FREQUENCY (how often you give it)	REPONSE	SIDE EFFECTS (if any)
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5

Non-Behavior Medications: Please complete the table below in regard to your pet’s current medications, dosages, and apparent effectiveness.

	MED NAME	DOSE (the mg strength)	FREQUENCY (how often you give it)	REPONSE	SIDE EFFECTS (if any)
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5

Medical History

Please list any newly diagnosed medical problems and how they were treated.

	Date	Diagnosis	Treatment (including medications and dosage)	Outcome
Medical Problem 1
Medical Problem 2
Medical Problem 3
Medical Problem 4
Medical Problem 5

Training
Is your dog attending a training class or do you have a trainer come to your home?*
Please give details, including name of trainer or facility:
What method of training is being utilized (i.e. clicker training, leash corrections, special collars, etc.):
Are you feeling successful with this training?
BITE HISTORY
Has your pet bitten since your last visit? *
Please list the number of bites that broke skin:
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?*

YesNo
Have you recently considered euthanasia (putting your dog to sleep)?*

YesNo
Has someone recently recommended you euthanize your pet?*

YesNo
Has the behavioral medicine clinic helped you with your pet?*
Please give us an update on how your pet is doing overall*
Scheduling

Please know that there are no late appointments on the schedule for the summer. Anything outside of the schedule will need to be approved and may incur an emergency fee.
Preferred days of week (Pick at least 2)*

Sunday (limited availability)Monday (12-3pm)Monday (3-8pm)Tuesday November 4thWednesdayThursday (Note: every other day is a mobile day for feline and select canine patients)My pet has only been seen mobileI believe my dog needs a mobile appointment (Pending Approval)None of these work for me.
Please be advised that mobile appointments require approval due to limited availability. Dr. Shana has designated specific days for mobile appointments, typically every other Thursday, and scheduling is dependent on location. Please note that we cannot guarantee a specific arrival time for mobile appointments, although we will make every effort to accommodate your schedule. If this does not work for you, we would love to have your pet seen in our hospital where appointment times are more predictable and there are less outside factors.*

I understand
Preferred Time Frame (pick at least 2)*

Sunday (any time)3-5pm5-7pmNone of these work for me
If you have scheduling limitations, please let us know below. Please know that we will try to accommodate to your schedule pending Dr. Gilbert-Gregory's availability but we may not be able.
Please list specific dates that will NOT work for you over the next 2 months. Please take into consideration the holiday season dates.*
I understand that this form is ONLY to be used for scheduling progress evaluations (appointments in person with Dr. Shana) *
This form is NOT to be used for scheduling phone calls, appointments with any other department in the hospital, or regular updates unless specifically asked.
DO NOT USE THIS FORM!
Should be Empty:

Progress Evaluation or Re-evaluation with Dr Shana

Please complete one form for each dog

This form is only to be used for scheduling Progress Evaluations with Dr. Shana.

Please complete the forms in their entirety

Medical History

Training

BITE HISTORY

CURRENT STATUS

Scheduling

DO NOT USE THIS FORM!