Patient Intake Form: Follow-Up Exam

1

Owner Name:* This field is required.

2

Patient Name:* This field is required.

3

Cell Phone Number (where you can be reached during your appointment):

4

What is the best CELL phone number to reach you TODAY to discuss your pet's care?* This field is required.

Area Code

Phone Number

5

Email

example@example.com

6

Make/Model/Color of the Vehicle You are Driving Today:* This field is required.

7

Is the original problem the same, better, or worse?* This field is required.

8

Do you have any new concerns?* This field is required.

9

If prescribed medication, are you having any issues with administration?* This field is required.

10

What medications are you currently giving your pet?* This field is required.

11

What is the pet's current diet (including treats)? Please specify brand, if known.* This field is required.

12

How often is your pet fed?* This field is required.

Once Daily

Twice Daily

Free Choice (Food available at all times)

13

Have you noticed any changes in your pet's appetite?* This field is required.

Increase

Decrease

No Change

14

What human food has your pet recently enjoyed?* This field is required.

15

Have you noticed any weight changes in your pet?* This field is required.

Increase

Decrease

No Change

16

Any changes in water consumption/thirst?* This field is required.

Increase

Decrease

No Change

17

Any increase in urination or accidents in the home?* This field is required.

Increase

Decrease

No Change

18

Any change in bowel movements?* This field is required.

Increase (Diarrhea)

Decrease (Constipation)

Normal / No Change

Unsure

19

What most accurately represents your pet's lifestyle* This field is required.

Inside exclusively (uses litter box or potty pads for eliminations)

Outside exclusively

Inside and Outside

20

If your pet has access to the outdoors, is it:* This field is required.

Outside supervised on a leash

Outside unsupervised - in a fenced area

Outside unsupervised - free roaming without fence

Pet never leaves the home

21

Date of most recent vaccinations:* This field is required.

Use best estimate if exact date is unknown.

22

Date of most recent heartworm test:* This field is required.

Use best estimate if exact date is unknown.

23

Date of most recent intestinal de-worming treatment:* This field is required.

Use best estimate if exact date is unknown.

24

Date of most recent labwork (CBC, Chemistry, etc):* This field is required.

Use best estimate if exact date is unknown.

25

Is your pet receiving monthly flea and tick prevention?* This field is required.

No

Yes

26

When was your last dose of flea and tick prevention given?* This field is required.

27

What brand of flea and tick medication are you using?* This field is required.

28

Is your pet receiving monthly heartworm prevention?* This field is required.

No

Yes

29

When was the last dose of heartworm medication administered?* This field is required.

30

What brand of heartworm medication are you using?* This field is required.

31

Are you interested in learning about the once-a-year heartworm prevention injection for dogs (Proheart 12)?* This field is required.Only available for dogs over 1 year of age.

Yes

No

My dog is already using this

32

Is your pet on any prescription medications? If so, what?* This field is required.

33

Is your pet receiving any over-the-counter supplements (vitamins, joint support, CBD, essential oils, etc)?* This field is required.

34

Any other important medical history?

35

Additional Notes:

36