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Patient Intake Form: Routine Visit
1
Client Name:
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2
Patient Name:
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3
What is the best phone number to reach you TODAY to discuss your pet's care?
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4
What is the best CELL phone number to reach you TODAY to discuss your pet's care?
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Area Code
Phone Number
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5
Email
*
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example@example.com
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6
Make/Model/Color of the Vehicle You are Driving Today:
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7
Routine services requested at today's visit:
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8
Is your pet experiencing any problems you would like to discuss with the veterinarian today?
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9
What is the pet's current diet (including treats)? Please specify brand, if known.
*
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10
How often is your pet fed?
*
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Once Daily
Twice Daily
Free Choice (Food available at all times)
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11
Have you noticed any changes in your pet's appetite?
*
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Increase
Decrease
No Change
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12
What human food has your pet recently enjoyed?
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13
Have you noticed any weight changes in your pet?
*
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Increase
Decrease
No Change
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14
Any changes in water consumption/thirst?
*
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Increase
Decrease
No Change
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15
Any increase in urination or accidents in the home?
*
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Increase
Decrease
No Change
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16
Any change in bowel movements?
*
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Increase (Diarrhea)
Decrease (Constipation)
Normal / No Change
Unsure
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17
What most accurately represents your pet's lifestyle?
*
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Inside exclusively (uses litter box or potty pads for eliminations)
Outside exclusively
Inside and Outside
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18
If your pet has access to the outdoors, is it:
*
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Outside supervised on a leash
Outside unsupervised - in a fenced area
Outside unsupervised - free roaming without fence
My pet never leaves our home
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19
Date of most recent vaccinations:
*
This field is required.
Use best estimate if exact date is unknown.
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20
Date of most recent heartworm test:
*
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21
Date of most recent intestinal de-worming treatment:
*
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Use best estimate if exact date is unknown.
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22
Date of most recent labwork (CBC, Chemistry, etc):
*
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Use best estimate if exact date is unknown.
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23
Is your pet receiving monthly flea and tick prevention?
*
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No
Yes
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24
When was your last dose of flea and tick prevention given?
*
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25
What brand of flea and tick medication are you using?
*
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26
Is your pet receiving monthly heartworm prevention?
*
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No
Yes
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27
When was the last dose of heartworm medication administered?
*
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28
What brand of heartworm medication are you using?
*
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29
Are you interested in learning about the once-a-year heartworm preventative for dogs (Proheart 12)?
*
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Yes
No
My dog is already using this
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30
Is your pet on any prescription medications? If so, what?
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31
Is your pet receiving any over-the-counter supplements (vitamins, joint support, CBD, essential oils, etc)?
*
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32
Does your pet have any known behavior problems or aggression issues (biting, separation anxiety, etc) that we should be aware of prior to exam?
*
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33
Does your pet have any known allergies or reactions to medications or vaccines?
*
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34
Any other important medical history?
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35
Additional Notes:
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