Oliver Animal Hospital - PATIENT CHECK IN FORM (old)

Client Information* This field is required.

Name

Phone

Please indicate below if any change in the following: mailing address or phone # or type in NA* This field is required.

Pet's Information

Pet's Name

Emergency contact & their phone # you want on file

Emergency contact E-mail Address if known

Reason for your pet's visit

Has your pet been prescribed medications to reduce anxiety and calm them while at the Vet? If so did you give those today?

What medication(s) did you administer to your pet to reduce anxiety and calm them?

What time did you give this/these medications today?

If you chose "OTHER" please list anxiety medication below* This field is required.

Diet Information* This field is required.

What kind of Diet are you feeding your pet and how much do you feed?

Have you changed your pet's diet (brand or flavor) within the last 60 days?

What treats or snacks are you feeding (brand/flavors)? Or enter "NONE"

Do you feed your pet anything other than dry/canned food or treats? (This includes any people food)

If Yes, please specify here

Is your pet currently on any supplement, prescribed medication, or vitamins? This question is important as we may need to prescribe a medication that could be contraindicated with what your pet is currently receiving at home. * This field is required.

Please list all supplements, prescribed medications, and vitamins below. Please include strength (mg or ml dose) and frequency below.* This field is required.

Do you need any refills of medications other than heartworm/flea/tick preventatives?

List medications that you would like refilled below

Do you give your pet heartworm prevention?* This field is required.

What is the brand of heartworm prevention you administer?* This field is required.If you can not find the brand then choose "other"

Heartgard Plus

Iverheart Plus

Triheart Plus

Ivermectin liquid

TRIFEXIS (heartworm + flea + intestinal parasite preventative)

Sentinel

Interceptor

Advantage Multi

Revolution

Heartgard for Cats

Proheart Injection (6 months)

Other

You selected "Other" please enter brand of heartworm prevention below* This field is required.

When did you last administer heartworm prevention to your pet?* This field is required.

Do you give your pet flea/tick prevention?* This field is required.

What is the brand of flea/tick prevention you administer?* This field is required.If you cannot find the brand choose "Other"

Nexgard

Advantage (fleas only/cat & dog product)

Advantix II (fleas & ticks/dog only product)

Revolution

Seresto Collar

Bravecto

Frontline Top Spot Plus

Pet Armor

Other

You chose "other" please enter in the flea/tick preventative brand below* This field is required.

When did you last administer the flea/tick medication?* This field is required.

Do you need refills of either heartworm or flea/tick preventatives? (Please indicate dosage amount below)

If you need a refill of heartworm prevention please indicate how many doses you would like to purchase

If you need a refill of flea/tick prevention please indicate how many doses you would like to purchase

Check all that apply to your pet's recent or past history* This field is required.

Allergy to Medication

Vaccine Reaction

Skin Allergies

Food Allergies

Inhaled Allergies

Urinary incontinence not controlled

Urinary Incontinence controlled

History of Cystitis

History of urinary blockage

Kidney Disease

Liver Disease

HYPER thyroidism (elevated thyroid level)

HYPO thyroidism (decreased thyroid level)

Congestive Heart Disease/Failure

Heart Murmur

Cancer

Lumps on the skin

Pancreatitis

Gasteroenteritis/Colitis

Sensitive Stomach

Feline Asthma

Cushing's Disease (Hyperadrenocorticism)

Addison's Disease (Hypoadrenocorticism)

Hypertension (High blood pressure)

Hip Dysplasia

Hind limb lameness/soreness/stiffness/slowness to rise

Forelimb lameness/soreness/stiffness/slowness to rise

Stress/Anxiety at vet-requires medication prior to visits

Fear Aggression

Difficulty with nail trims

Ear infection(s)

Eye Issues (cataracts, conjunctivitis, dry eye, corneal ulcer, enucleation)

Upper Respiratory Infections

Bone Fracture

Seizures or Convulsions

Changes in Attitude or Behavior

Loss of Stamina

Thunderstorm Phobia

No Medical Issues

Gallbladder disease

If you need to tell us more then see next field

What other conditions has your pet experienced ? Enter answer(s) below

Has your pet had any vomiting?* This field is required.

Yes

If your pet had any vomiting, please Specify* This field is required.

How many days has your pet been vomiting?

How many times per day does your pet vomit?

What does vomit look like or contain?

If other, please specify

Is your pet experiencing diarrhea?* This field is required.

Yes

If your pet experiencing diarrhea, please specify* This field is required.

When did the diarrhea start?

How frequent is the diarrhea? ( x per day )

Straining to defecate?

Mucous in stool?

Blood in stool?

Do you think your pet may be constipated or defecating less often?

Any coughing?* This field is required.

Yes

If any coughing, please specify* This field is required.

When did it start?

How frequent is the cough?

Is the cough productive?

Is there a gag at the end of the cough?

Any Sneezing?* This field is required.

Yes

If nasal discharge present please choose from the answers below* This field is required.

CLEAR DISCHARGE

YELLOW OR GREEN DISCHARGE

BLOOD MIXED IN WITH DISCHARGE

FRANK BLOOD

BOTH NOTRILS

LEFT NOSTRIL

RIGHT NOSTRIL

UNSURE WHICH NOSTRIL

Any Lameness?* This field is required.

Yes

* This field is required.

Which limb is affected?

When did the lameness start?

Does lameness get better with rest?

Slow to rise?

Moving around less?

Still able to jump up or down like normal?

Have you given any supplements or injectable adequan for lameness/stiffness/slowness to rise or move around?

Any new masses?* This field is required.

Yes

Where are the new masses located on your pet?* This field is required.

Any increase in water consumption?* This field is required.

Yes

Is your pet experiencing any urinary issues?* This field is required.

Yes

Please select all that apply from the clinical signs or behavior (s) below* This field is required.

INAPPROPRIATE URINATION IN THE HOME

PASSIVE URINATION WHEN SLEEPING OR AT REST

STRAINING TO URINATE

BLOOD OR OTHER DISCOLORATION TO URINE

PASSING SMALL AMOUNTS OF URINE

NOT ABLE TO URINATE

IF INTACT MALE DOG-BLOOD SEEN FROM PREPUCE IRREGARDLESS OF URINATING

CATS-YOWLING/CRYING OUT WHEN IN LITTER BOX

CATS-GETTING IN AND OUT OF LITTER BOX

CATS OR DOGS-LICKING UROGENITAL REGION

CATS-SPRAYING FURNITURE/WALLS/NEAR DOORS/WINDOWS

CATS-URINATING ON FURNITURE OR ITEMS LEFT ON THE FLOOR (EX. CLOTHING, PILLOWS)

* This field is required.

When did the inappropriate urination start?

If you have more than one cat how many litter boxes do you have available?

Does your pet seem itchy?* This field is required.

Yes

* This field is required.

If your pet seems itchy please select all areas that are bothering them

How long has your pet had skin or ear issues? Chronic, Intermittent, or New Issue?

Are you concerned about your pet's weight?* This field is required.

Is your pet on a prescribed or OTC (Venison, Kangaroo, Rabbit, Duck) hypoallergenic diet? Grain free is not considered a hypoallergenic diet when you answer this question.* This field is required.

Have you done an 8-12 week prescription hypoallergenic diet food trial with your pet?* This field is required.

Do you need a refill of your pet's prescription diet? Choose all that apply* This field is required.

YES

I would like you to order my pet's diet from your online pharmacy

When did you last feed your pet?

When did your pet last urinate?

Has your pet been bitten by another animal within the last 2 years?

Is your pet's rabies vaccination current?

Do you have a preferred pharmacy? List name of pharmacy with both cross streets)

Do you use our online pharmacy where medications/food/preventatives are mailed to you when you need them?