Oliver Animal Hospital - PATIENT CHECK IN FORM

Name

Phone

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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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Pet's Name

Emergency contact & their phone # you want on file

Emergency contact E-mail Address if known

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?

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If you chose "OTHER" please list anxiety medication below

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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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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 )

How frequently are you feeding your pet?

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

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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?

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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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

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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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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 monthly?

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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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You selected "Other" please enter brand of heartworm prevention below

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When did you last administer heartworm prevention to you pet?

Do you give your pet flea/tick prevention?

What brand of flea & tick prevention?

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You chose "other" please enter in the flea/tick preventative brand below

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When did you last administer the flea/tick medication?

If you need refill of either heartworm or flea/tick preventatives please indicate 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

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

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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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What does vomit look like or contain?

If other, please specify

Is your pet experiencing diarrhea?

When did the diarrhea start?

How frequent is the diarrhea? ( x per day )

Straining to defecate?

Mucous in stool?

Blood in stool?

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

Any coughing?

If coughing then 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?

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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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Has your dog been to any dog parks, boarded, attended day care or exposed to other dogs within the last 2 weeks?

Any lameness?

If lameness present then which limb is affected?

When did lameness start?

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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?

Where are the new masses located on your pet?

Any increase in water consumption?

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Is your pet experiencing any urinary issues? If so choose 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)

None

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When did the inappropriate urination start?

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

If your pet seems itchy please note down below what areas are bothering them

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

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

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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

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

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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

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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?

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