ECV - Preventive Exam Health History

1
Your Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Pet's Name* This field is required.
4
Species* This field is required.
Please Select
Please Select
Dog
Cat
Rabbit
Ferret
Bird
Reptile
Small mammal
Potbellied pig
Other
5
Sex
Please Select
Please Select
Male
Male Neutered
Female
Female Spayed
Unsure
6
Are you a new client?* This field is required.
YESNO
7
Have you completed the new patient form?
YESNO
8
Please fill out the New Patient form. When done, click "next".
9
What issues/problems is {petsName129} experiencing?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
10
When was the issue/problem first noted?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
11
Is the problem the same, better, or worse today?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
12
Has a similar problem happened in the past?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
13
Have you noticed any changes in your pet's weight?
Please Select
Please Select
Increased
Decreased
No change
14
Have you noticed any changes in your pet's bowel movements?
Please Select
Please Select
Increased
Decreased
Normal
15
What type of food are you feeding {petsName129}?* This field is required.
16
How much do you feed {petsName129}?* This field is required.
17
How often do you feed {petsName129}?* This field is required.
18
Have you noticed any changes in your pet's eating habits?* This field is required.
Please Select
Please Select
Increased
Decreased
Normal
19
Have you seen any ticks on {petsName129}?* This field is required.
Please Select
Please Select
Yes
No
Unsure
20
Have you seen any fleas on {petsName129}?* This field is required.
Please Select
Please Select
Yes
No
Unsure
21
If you have other pets, have you seen any fleas on them? {petsName129}?* This field is required.
Please Select
Please Select
Yes
No
Unsure
Do Not Have Other Pets
22
What percentage of time does {petsName129} spend outside?
23
Is {petsName129} taking any medications or supplements? * This field is required.
Please Select
Please Select
Yes
No
Unsure
24
What medications, strength and frequency?
25
What is {petsName129}'s water source?* This field is required.
26
How often is it changed?* This field is required.
27
Have you noticed any changes in {petsName129}'s water consumption?* This field is required.
Please Select
Please Select
Increased
Decreased
Normal
28
What additional concerns or questions do you have?
Huge
Large
Normal
Small
Ok
Ok
29
Birds

Our veterinarians find some additional background information on {petsName129} can be helpful for their appointment:
30
Length of time owned? * This field is required.
31
Where was {petsName129} acquired?
32
Any other birds?* This field is required.
YESNO
33
Are they housed together or singly?
Please Select
Please Select
Together
Singly
34
Any other pets?
YESNO
35
How often is {petsName129} handled?* This field is required.
36
Is {petsName129} ever taken outside?* This field is required.
YESNO
37
When was the last molt? Any trouble?* This field is required.
38
For the next question, please take note of the current state of your bird's droppings.
39
Fecal consistency?* This field is required.
40
Have you noticed any changes in your pet's bowel movements?* This field is required.
Please Select
Please Select
Increased
Decreased
Normal
41
What type of enclosure does {petsName129} have?* This field is required.
42
Size of {petsName129}'s enclosure?* This field is required.
43
Where is {petsName129}'s enclosure located in your home?* This field is required.
44
Type of cage substrate?* This field is required.
45
How frequently is it cleaned and what it used for cleaning?* This field is required.
46
What types of toys/perches are offered?* This field is required.
47
Types of food offered:
Pellets
Seed
Fruits
Vegetables
Other
48
Have you noticed any changes in your pet's eating habits?* This field is required.
Please Select
Please Select
Increased
Decreased
No change
49
What brand and amount fed/frequency?
50
What brand and amount fed/frequency?
51
What brand and amount fed/frequency?
52
What brand and amount fed/frequency?
53
Ferret, Rabbit, Small Mammals

Our veterinarians find some additional info helpful for small mammal appointments.

Background Information on {petsName129}:
54
Length of time owned?* This field is required.
55
Where was it acquired?* This field is required.
56
Any other small mammals?* This field is required.
YESNO
57
Are they housed together or singly? * This field is required.
Please Select
Please Select
Together
Singly
58
Any other pets?
YESNO
59
How often is {petsName129} handled?* This field is required.
60
Is {petsName129} ever taken outside?* This field is required.
YESNO
61
For the next question, please take note of your rabbit's droppings.
62
Fecal consistency?* This field is required.
63
Have you noticed any changes in your pet's bowel movements?* This field is required.
Please Select
Please Select
Increased
Decreased
Normal
64
What type of enclosure does {petsName129} have?* This field is required.
65
Size of {petsName129}'s enclosure?* This field is required.
66
Where is {petsName129} 's enclosure located in your home?* This field is required.
67
Type of cage substrate (substrate is the material in the bottom of the cage)?* This field is required.
68
How frequently is it cleaned and what is used for cleaning?* This field is required.
69
What types of cage furniture and chew toys are available?* This field is required.
70
Type of food offered?
Pellets
Hay
Other
71
What brand and amount fed/frequency?
72
What brand and amount fed/frequency?
73
Have you noticed any changes in your pet's eating habits? * This field is required.
Please Select
Please Select
Increased
Decreased
Normal
74
REPTILES

Background Information:
75
Length of time owned?* This field is required.
76
Where was it acquired?* This field is required.
77
Any other reptiles?* This field is required.
YESNO
78
Are they housed together or singly?* This field is required.
Please Select
Please Select
Together
Singly
79
Any other pets?* This field is required.
YESNO
80
How often is {petsName129} handled?* This field is required.
81
Is {petsName129} ever taken outside?* This field is required.
YESNO
82
When was the last shed? Any trouble?* This field is required.
83
Fecal consistency?* This field is required.
84
Have you noticed any changes in your pet's bowel movements?* This field is required.
Please Select
Please Select
Increased
Decreased
Normal
85
What type of enclosure does {petsName129} have?* This field is required.
86
Size of {petsName129}'s enclosure?* This field is required.
87
Where is {petsName129}'s enclosure located in your home?* This field is required.
88
Type of cage substrate?* This field is required.
89
How frequently is it cleaned and what is used for cleaning?* This field is required.
90
Type of lighting and what light cycle is used?* This field is required.
91
What heat sources are used?* This field is required.
92
What are the minimum and maximum temperatures in the enclosure?* This field is required.
93
Humidity level?* This field is required.
94
Type of food offered?* This field is required.
95
Frequency and amount fed?* This field is required.
96
When was the last feeding?* This field is required.
97
Have you noticed any changes in your pet's eating habits?* This field is required.
Please Select
Please Select
Increased
Decreased
Normal
98
We look forward to seeing {petsName129} soon. In preparation for your upcoming appointment, we ask:

Please arrive 10 minutes prior to your scheduled time with the doctor to ensure your check-in is complete.

When you arrive, please come inside to check-in for your pet’s appointment.

If your pet is anxious or more comfortable remaining in the vehicle until we have an exam room ready please call the phone number on the sign. If the phone line is busy we are checking in another client, please wait a minute and try again.

If you are more than 10 minutes late to your scheduled appointment we will need to reschedule the appointment to ensure other clients are seen in a timely manner.

If you need to cancel or reschedule your appointment, please contact us at least 48 hours before your scheduled appointment.

All pets must be on a secure leash or in a carrier.

Thanks,

East Central Veterinarians Team
Should be Empty:

BirdsOur veterinarians find some additional background information on {petsName129} can be helpful for their appointment:

We look forward to seeing {petsName129} soon. In preparation for your upcoming appointment, we ask:

Birds

Our veterinarians find some additional background information on {petsName129} can be helpful for their appointment: