Patient Intake Form: Routine Visit

1

Client Name:* This field is required.

2

Patient Name:* This field is required.

3

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

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* This field is required.

example@example.com

6

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

7

Routine services requested at today's visit:* This field is required.

8

Is your pet experiencing any problems you would like to discuss with the veterinarian today?* This field is required.

9

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

10

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

Once Daily

Twice Daily

Free Choice (Food available at all times)

11

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

Increase

Decrease

No Change

12

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

13

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

Increase

Decrease

No Change

14

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

Increase

Decrease

No Change

15

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

Increase

Decrease

No Change

16

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

Increase (Diarrhea)

Decrease (Constipation)

Normal / No Change

Unsure

17

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

18

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

My pet never leaves our home

19

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

Use best estimate if exact date is unknown.

20

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

21

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

Use best estimate if exact date is unknown.

22

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

Use best estimate if exact date is unknown.

23

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

No

Yes

24

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

25

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

26

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

No

Yes

27

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

28

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

29

Are you interested in learning about the once-a-year heartworm preventative for dogs (Proheart 12)?* This field is required.

Yes

No

My dog is already using this

30

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

31

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

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?* This field is required.

33

Does your pet have any known allergies or reactions to medications or vaccines?* This field is required.

34

Any other important medical history?

35

Additional Notes: