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Oliver Animal Hospital - PATIENT CHECK IN FORM
1
Name
Email
Phone
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2
Please indicate below if any change in the following: mailing address or phone # or type in NA
*
This field is required.
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3
Pet's Name
Emergency contact & their phone # you want on file
Emergency contact E-mail Address if known
Yes
No
Yes
No
Has your pet been prescribed medications to reduce anxiety and calm them while at the Vet? If so did you give those today?
GABAPENTIN
TRAZODONE
BUPRENEX
ALPRAZOLAM (XANAX)
LORAZEPAM
ZYLKENE
ACEPROMAZINE
OTHER
NONE
GABAPENTIN
TRAZODONE
BUPRENEX
ALPRAZOLAM (XANAX)
LORAZEPAM
ZYLKENE
ACEPROMAZINE
OTHER
NONE
What medication(s) did you administer to your pet to reduce anxiety and calm them?
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4
If you chose "OTHER" please list anxiety medication below
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5
What time did you give this/these medications today?
What dry diet are you currently feeding (brand name & flavor (s)) or type in "None"*
Amount of dry fed in cups AM
Amount of dry fed in cups PM
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6
What canned diet are you currently feeding (brand name and flavor(s)) or enter "NONE"
Amount of canned food fed per day ( Can AM )
Amount of canned food fed per day ( Can PM )
MORNING
MID DAY
EVENING
MORNING ONLY
EVENING ONLY
MORNING
MID DAY
EVENING
MORNING ONLY
EVENING ONLY
How frequently are you feeding your pet?
YES
NO
YES
NO
Have you changed your Pet's diet (brand or flavor) within the last 60 days?
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7
What treats or snacks are you feeding (brand/flavor(s))? Or enter "NONE"
How many treats or snacks do you feed your pet per day?
YES
NO
YES
NO
Do you feed your pet anything other than dry/canned food or treats? (This includes any people food)
If Yes, then enter that information
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8
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.
*
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9
Please list all supplements, prescribed medications, and vitamins below. Please include strength (mg or ml dose) and frequency below. Or type in "NONE"
*
This field is required.
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10
YES
NO
YES
NO
Do you need any refills of medications other than heartworm/flea/tick preventatives?
List medications that you would like refilled below
YES
NO
YES
NO
Do you give your pet heartworm prevention monthly?
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11
What is the brand of heartworm prevention you administer?
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 q 6 mos
Other
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12
You selected "Other" please enter brand of heartworm prevention below
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13
Within the last 30 days
2 months
3 months
4 months
5 months
6 months or greater
Within the last 30 days
2 months
3 months
4 months
5 months
6 months or greater
When did you last administer heartworm prevention to you pet?
YES
NO
YES
NO
Do you give your pet flea/tick prevention?
Nexgard
Advantage (fleas only/cat & dog product)
Advantix II (fleas & ticks/dog only product)
Revolution
Seresto Collar
Bravecto
Frontline Top Spot Pus
Pet Armor
Other
Nexgard
Advantage (fleas only/cat & dog product)
Advantix II (fleas & ticks/dog only product)
Revolution
Seresto Collar
Bravecto
Frontline Top Spot Pus
Pet Armor
Other
What brand of flea & tick prevention?
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14
You chose "other" please enter in the flea/tick preventative brand below
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15
Within the last 30 days
2 months
>2 months
Within the last 30 days
2 months
>2 months
When did you last administer the flea/tick medication?
HEARTWORM PREVENTATIVE REFILL
FLEA/TICK PREVENTATIVE REFILL
NONE
HEARTWORM PREVENTATIVE REFILL
FLEA/TICK PREVENTATIVE REFILL
NONE
If you need refill of either heartworm or flea/tick preventatives please indicate below
1 dose
2 doses
3 doses
4 doses
5 doses
6 doses
12 doses
1 dose
2 doses
3 doses
4 doses
5 doses
6 doses
12 doses
If you need a refill of heartworm prevention please indicate how many doses you would like to purchase
1 dose
2 doses
3 doses
4 doses
5 doses
6 doses
12 doses
1 dose
2 doses
3 doses
4 doses
5 doses
6 doses
12 doses
If you need a refill of flea/tick prevention please indicate how many doses you would like to purchase
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16
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
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17
What other conditions has your pet experienced ? Enter answer(s) below
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18
YES
NO
YES
NO
Has your pet had any vomiting?
If you pet has had vomiting please tell us approximately when it started
If vomiting then how frequently?
Number of vomit episodes total? ( TOTAL # OF EPISODES= )
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19
DIGESTED FOOD
PARTIALLY OR UNDIGESTED FOOD
FOREIGN MATERIAL (ie. plastic, stuffing, pieces of toy, fabric)
BRIGHT RED BLOOD
FROTHY LIGHT PINK FLUID
COFFEE GROUND APPEARANCE TO VOMIT CONTENTS
BILE (orange/yellow/green fluid)
CLEAR FLUID
OTHER
DIGESTED FOOD
PARTIALLY OR UNDIGESTED FOOD
FOREIGN MATERIAL (ie. plastic, stuffing, pieces of toy, fabric)
BRIGHT RED BLOOD
FROTHY LIGHT PINK FLUID
COFFEE GROUND APPEARANCE TO VOMIT CONTENTS
BILE (orange/yellow/green fluid)
CLEAR FLUID
OTHER
What does vomit look like or contain?
If other, please specify
YES
NO
YES
NO
Is your pet experiencing diarrhea?
When did the diarrhea start?
How frequent is the diarrhea? ( x per day )
YES
NO
YES
NO
Straining to defecate?
YES
NO
YES
NO
Mucous in stool?
YES
NO
YES
NO
Blood in stool?
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20
YES
NO
YES
NO
Do you think your pet may be constipated or defecating less often?
YES
NO
YES
NO
Any coughing?
If coughing then when did it start?
How frequent is the cough?
YES
NO
YES
NO
Is the cough productive?
YES
NO
YES
NO
Is there a gag at the end of the cough?
YES
NO
YES
NO
Any Sneezing?
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21
If nasal discharge present please choose from the answers below
CLEAR DISCHARGE
YELLOW OR GREEN DISCHARGE
BLOOD MIXED IN WITH DISCHARGE
FRANK BLOOD
BOTH NOTRILS
LEFT NOSTRIL
RIGHT NOSTRIL
UNSURE WHICH NOSTRIL
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22
YES
NO
YES
NO
Has your dog been to any dog parks, boarded, attended day care or exposed to other dogs within the last 2 weeks?
YES
NO
YES
NO
Any lameness?
RIGHT FRONT LEG
LEFT FRONT LEG
RIGHT HIND LEG
LEFT HIND LEG
UNSURE WHICH FORELIMB
UNSURE WHICH HINDLIMB
RIGHT FRONT LEG
LEFT FRONT LEG
RIGHT HIND LEG
LEFT HIND LEG
UNSURE WHICH FORELIMB
UNSURE WHICH HINDLIMB
If lameness present then which limb is affected?
When did lameness start?
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23
YES
NO
YES
NO
Does lameness get better with rest?
YES
NO
YES
NO
Slow to rise?
YES
NO
YES
NO
Moving around less?
YES
NO
YES
NO
Still able to jump up or down like normal?
YES
NO
YES
NO
Have you given any supplements or injectable adequan for lameness/stiffness/slowness to rise or move around?
YES
NO
YES
NO
Any new masses?
Where are the new masses located on your pet?
YES
NO
YES
NO
Any increase in water consumption?
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24
Is your pet experiencing any urinary issues? If so choose from the clinical signs or behavior (s) below
*
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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)
None
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25
When did the inappropriate urination start?
1
2
3
4
5
6
7
8
N/A
1
2
3
4
5
6
7
8
N/A
If you have more than one cat how many litter boxes do you have available?
EARS
SKIN
FACE
REAR END
EARS
SKIN
FACE
REAR END
If your pet seems itchy please note down below what areas are bothering them
CHRONIC
INTERMITTENT/SEASONAL
INTERMITTENT/NON SEASONAL
FIRST EPISODE
CHRONIC
INTERMITTENT/SEASONAL
INTERMITTENT/NON SEASONAL
FIRST EPISODE
How long has your pet had skin or ear issues? Chronic, Intermittent, or New Issue?
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26
Are you concerned about your pet's weight?
*
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YES
NO
YES
NO
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27
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.
YES
NO
YES
NO
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28
Have you done an 8-12 week prescription hypoallergenic diet food trial with your pet?
*
This field is required.
YES
NO
MY PET IS CURRENTLY ON A FOOD TRIAL
YES
NO
MY PET IS CURRENTLY ON A FOOD TRIAL
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29
Do you need a refill of your pet's prescription diet? Choose all that apply
*
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YES
I would like you to order my pet's diet from your online pharmacy
NO
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30
Last night
This morning
Last night
This morning
When did you last feed your pet?
< 1 hr ago
>1 hr but
>4 hrs
I am unsure
< 1 hr ago
>1 hr but
>4 hrs
I am unsure
When did your pet last urinate?
YES
NO
YES
NO
Has your pet been bitten by another animal within the last 2 years?
YES
NO
UNSURE
YES
NO
UNSURE
Is your pet's rabies vaccination current?
Do you have a preferred pharmacy? List name of pharmacy with both cross streets)
No, but I would like to start using your online pharmacy. Please give me more information
No, I am not interested in using your online pharmacy
Yes, I already use your online pharmacy
No, but I would like to start using your online pharmacy. Please give me more information
No, I am not interested in using your online pharmacy
Yes, I already use your online pharmacy
Do you use our online pharmacy where medications/food/preventatives are mailed to you when you need them?
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