Brook-Falls Form

1

Which Form Would You Like to Fill Out?

Check In (Canine)

Check In (Feline)

Small Mammal New Patient Form

2

Name

First Name

Last Name

3

Dog's Name:

4

Breed:

5

Color:

6

Date of Birth/Age

7

Sex

Male

Female

Neutered

Spayed

8

Primary Reason for Today's Visit (also any additional concerns you may have).

9

Behavior

Good/Normal

Lethargic

Aggressive

Withdrawn

10

Do You Have Any Concerns Today?

11

PET HISTORY: How Long have you owned your dog?

12

Where did you get your dog?

13

Is your dog boarded or go to Doggy Day Care

Yes

No

14

Do you travel with your dog?

No

Yes

15

If you do travel with your dog - Where?If you don't, just click Next

16

Is your pet microchipped?

Yes

No

17

What brand of food do you feed your dog?

18

Amount fed per day?

19

How do you feed your dog?

Once daily

Twice daily

Other

20

If you feed treats, what kind and how many per day?

21

Do you give any medication/supplements to your dog?

Medication #1

How Often and Time Last Given.

Medication # 2

How Often and Time Last Given

Medication # 3

How Often and Time Last Given

22

Do you need any food or medication refills today?

Yes

No

23

If additional food or medication refills are needed, please list them below:

24

Has your pet ever had a bad reaction to any medication? If so, please describe below:

25

Is your pet on year round heartworm prevention?

Yes

No

26

If yes, which brand of Heartworm prevention?

27

When was the last dose given?

28

Do you need a refill on Heartworm prevention today?

Yes

No

29

What brand of Flea/Tick prevention do you administer?

30

When was the last dose of flea/tick prevention given?

31

Do you brush your pet's teeth or use any dental care products? If so, please list the products used and frequency of use:

32

Has your pet ever had a reaction to a vaccination?

Yes

No

33

Please describe the adverse reaction (if applicable)

34

Please bring a fresh fecal sample for testing to your appointment.

35

Cat's Name:

36

Breed:

37

Color:

38

Date of Birth/Age

39

Sex

Male

Female

Neutered

Spayed

40

Primary Reason for Today's Visit (also any additional concerns you may have).

41

Behavior

Good/Normal

Lethargic

Aggressive

Withdrawn

42

Do You Have Any Concerns Today?

43

PET HISTORY: How Long have you owned your cat?

44

Where did you get your cat?

45

What brand of food do you feed your cat?

46

How do you feed your cat?

Once daily

Twice daily

Other

47

Amount fed per day?

48

If you feed treats, what kind and how many per day?

49

Does your cat go outside?

Yes

No

50

If your cat does go outside, please describeIf he/she doesn't, just click Next

51

Is your pet microchipped?

Yes

No

52

Do you give any medication/supplements to your cat?

Medication #1

How Often and Time Last Given.

Medication # 2

How Often and Time Last Given

Medication # 3

How Often and Time Last Given

53

Do you need any food or medication refills today?

Yes

No

54

If additional food or medication refills are needed, please list them below:

55

Has your pet ever had a bad reaction to any medication? If so, please describe below:

56

Is your pet on year round heartworm prevention?

Yes

No

57

If yes, which brand of Heartworm prevention?

58

When was the last dose given?

59

Do you need a refill on Heartworm prevention today?

Yes

No

60

What brand of Flea/Tick prevention do you administer?

61

When was the last dose of flea/tick prevention given?

62

Do you brush your cat's teeth or use any dental care products? If so, please list the products used and frequency of use:

63

Has your cat ever had a reaction to a vaccination?

Yes

No

64

Please describe the adverse reaction (if applicable)

65

Please bring a fresh fecal sample for testing to your appointment.

66

Pet's Name:

67

Species/Breed:

68

Color:

69

Date of Birth/Age

70

Primary Reason for Today's Visit (also any additional concerns you may have).

71

Behavior

Good/Normal

Lethargic

Aggressive

Withdrawn

72

Do You Have Any Concerns Today?

73

PET HISTORY: How Long have you owned your pet?

74

Where did you get your pet?

75

Is your pet microchipped?

Yes

No

76

What food and treat(s) do you feed your pet? (include how often and amount)

77

Any recent diet changes? If yes, please describe:

78

Is your pet living Indoor, Outdoor, or Both? (if both, please describe)

79

Is your pet housed alone or with another pet? (If yes - indicate ages and sex of cage mates)

80

Where/How is your pet housed (include cage material, cage size, water bottle vs crock) ?

81

What substrate/bedding do you use, how often is it changed?

82

Does your pet use a litter box, if yes, what type of litter?

83

Describe how you clean the cage (include cleaning supplies, method used, frequency, etc).

84

Is your pet allowed outside of the cage? If yes, please describe:

85

What grooming services do you provide? (e.g., brushing/grooming, dust baths for chinchillas, nail trims, etc. and how often).

86

Do you give any medication/supplements to your pet?

Medication #1

How Often and Time Last Given.

Medication # 2

How Often and Time Last Given

Medication # 3

How Often and Time Last Given

87

Do you need any food or medication refills today?

Yes

No

88

If additional food or medication refills are needed, please list them below:

89

(FOR FERRETS) Is your pet on year round heartworm prevention?

Yes

No

90

If yes, which brand of Heartworm prevention?

91

When was the last dose given?

92

Do you need a refill on Heartworm prevention today?

Yes

No

93

Does your pet have exposure to ticks any time of the year?

94

What brand of Flea/Tick prevention do you administer?

95

When was the last dose of flea/tick prevention given?

96

FOR FERRETS: Has your pet ever had any vaccinations?

Yes

No

97

List the kind of vaccinations and when they were given (if applicable).