History Intake Form

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Name *

First

Last

Phone *

Your Pet's Name *

My Pet is a: *

I believe my appointment is scheduled at: *

Westonka Animal Hospital (next to Mound Jubilee grocery)
Lake Minnetonka Pet Wellness Center (next to Dairy Queen in Navarre)

My Pet's appointment date is:

Current Diet Fed, including supplements and treats:

Primary Reason for Appointment *

Life Stage Wellness Exam Preventative Care
Technician Office Call
Medical Progress Exam w/ Doctor ("Recheck")
Pre-Surgery Exam w/ Doctor
Scheduled Surgery &_or Dentistry Care
Follow-Up Test &_or Procedure
Coughing &_or Sneezing
Ear(s) problem
Eye(s) problem
Skin wound &_or toe nail problem
Limping
Skin Growth &_or Tumor &_or Swelling
Skin Issue &_or Hair Loss &_or Itchy
Vomiting &_or Diarrhea
Lethargy &_or Decreased Activity
Other Reason

Other Reason for Appointment *

Behavior - aggression towards other pets
Behavior - inappropriate urination or defecation
Behavior - general fear & anxiety
Behavior - separation anxiety &_or fear of loud noises
Drinking more water &_or Urinating Larger Volume
Decreased Appetite &_or Weight Loss
Travel Health Certificate
Quality of Life Discussion; or Euthanasia &_or Cremation
Second Opinion
Other Reason not listed previously

Scheduled Surgery or Dentistry Care

Which surgery(s) will you be bringing your pet in for?

Spay
Neuter
Hernia Repair
Professional Dentistry Care / Visit
Tumor(s) or Growth(s) to be removed
Other scheduled surgery

Life Stage Wellness Exams are examinations with the purpose of doing a complete exam and discussing nutrition, oral health care, preventative care, minor behavior concerns. We set aside shorter lengths of time for these exams. If you have a concern such as vomiting, diarrhea, limping, itching, coughing stop here, go back and unclick the Life Stage Wellness Exam option and click on the correct primary symptom or concern so that we may schedule an exam time length which is appropriate for the condition(s) or concern(s).
If your purpose is for the Wellness Exam as described above, please continue. Next, we calculate your pet's Life Stage (1 to 4) and ask some questions about your pet's lifestyle so we can customize our recommendations for your unique pet.

How old is your pet?

Age Units

Estimated or Last Known Weight (lbs.)
Estimated or Last Known Pet Weight in Pounds

Cat Life 1
Your Kitten is 'Life Stage 1'.

Cat Life 2
Your Cat is Life Stage 2, a young adult. Although it is up to the examining doctor's discretion, generally we recommend (not require) that Life Stage 2 exam patients have: a "internal physical exam" which is a smaller blood chemistry panel and an intestinal parasite examination (we will need a fresh feces sample)

Cat Life 3
Your Cat is Life Stage 3, an older adult. Although it is up to the examining doctor's discretion, generally we recommend (not require) that Life Stage 3 exam patients have: a "internal physical exam" which is a smaller blood chemistry panel and an intestinal parasite examination (we will need a fresh feces sample). a urine analysis, a blood pressure, and a thyroid hormone level test.

Cat Life 4
Your Cat is Life Stage 4, an older adult. Although it is up to the examining doctor's discretion, generally we recommend (not require) that Life Stage 4 exam patients have: a "internal physical exam" which is a smaller blood chemistry panel and an intestinal parasite examination (we will need a fresh feces sample). a urine analysis, a blood pressure, and a thyroid hormone level test.

Dog Life 1
Your Puppy is Life Stage 1

Dog Life 2
Your dog is Life Stage 2 a young adult. Although it is up to the examining doctor's discretion, generally we recommend (not require) that Life Stage 2 exam patients have: a "internal physical exam" which is a smaller blood chemistry panel and an intestinal parasite examination (we will need a fresh feces sample).

Dog Life 3
Your Dog is Life Stage 3, an older adult. Although it is up to the examining doctor's discretion, generally we recommend (not require) that Life Stage 3 exam patients have: a "internal physical exam" which is a smaller blood chemistry panel and an intestinal parasite examination (we will need a fresh feces sample). a urine analysis, and a thyroid hormone level test.

Dog Life 4
Your Dog is Life Stage, an older adult. Although it is up to the examining doctor's discretion, generally we recommend (not required) that Life Stage 4 exam patients have: a "internal physical exam" which is a smaller blood chemistry panel and an intestinal parasite examination (we will need a fresh feces sample). a urine analysis, and a thyroid hormone level test.

Your Cat's Lifestyle Does / Will Include:
Spending all time indoors
Living with 2 or more other cats
Living with a dog(s).
Playing with family members
Spending time outdoors supervised , time spent on deck or porch or on leash
Spending time outdoors unsupervised

Do I want to evaluate and discuss my older cat's mobility with a quick checklist?
Yes, I would like to complete a quick checklist
No, I just want to finish these questions

Cat Joint Disease Animations
Link to Zoetis Pet Care page with helpful and clear animations showing difference between cats with healthy joints and those with joint disease. Very informative page ! You do NOT have to complete a personalized report on that page, just review the animations.

After reviewing the Zoetis Pet Care animations, I would like to discuss the following mobility concerns about my older cat: like to mention the following mobility changes:
Jumping up or jumping down
Going up or down stairs
Changes in chasing objects
Changes in running ability

Behavior Assessment of Older Cats

Helps us to identify behavior changes associated with aging since your cat is 11 years of age and older.

Would you like to complete the cat cognitive assessment checklist?
Yes, I would like to complete the checklist
No, I just want to finish these questions

Cat Cognitive Assessment Checklist (please select all that apply)
Spatial disorientation or confusion (examples: getting trapped in corners or forgetting the location of the litter box).
Altered social relationships with owners or other pets in the household (examples: increased or decreased attention seeking with owners or other pets in the household.
Altered behavioral responses (examples: increased irritability or anxiety or decreased response to stimuli).
Changes in sleep/wake patterns.
Inappropriate vocalization (example: loud crying at night).
Changes in activity (examples: aimless wandering or pacing, or reduced activity).
Altered interest in food, either increased or, more typically, decreased.
Decreased grooming.

Your Dog's Lifestyle Does / Will Include:
Interacting with other dogs outside of our home
Interacting with other dogs inside of our home
Groomer or kennel visits
Playing with family / children
Visiting ponds (not including lakes)
Hunting
Walking in tall grass
Camping
Visiting a cabin

Is this your young pet's first visit with us?
Yes
No

Where did you get your new pet?

Any additional health concerns?

Do you know the Feline Leukemia or Feline Immunodeficiency Virus status?

Is your pet on heartworm prevention?
Yes
No

What is the name of the heartworm preventative?

Is your pet on flea and tick prevention?
Yes
No

What is the name of the flea & tick preventative?

Additional Current Medications
- current medications -

Behavior Assessment of Older Dogs

Identify behaviors that have arisen or changed since 8 years of age and older. DISHAA is a tool to help you and veterinarians assess the mental acuity of your dog, and for veterinarians to potentially diagnose Cognitive Dysfunction Syndrome (CDS). The tool takes about 2 minutes to complete. Would you like to complete the mental acuity test?

Would you like to complete the dog cognition mental acuity tool?
Yes, I would like to complete the acuity tool.
No, I just want to finish these questions

Score as 0=none, 1=mild, 2=moderate, 3=severe

Gets stuck, difficulty getting around objects, goes to hinge side of door
0
1
2
3
Score as 0=none, 1=mild, 2=moderate, 3=severe

Stares blankly at walls, floor, or into space
0
1
2
3
Score as 0=none, 1=mild, 2=moderate, 3=severe

Does not recognize familiar people / familiar pets
0
1
2
3
Score as 0=none, 1=mild, 2=moderate, 3=severe

Gets lost in home or yard
0
1
2
3
Score as 0=none, 1=mild, 2=moderate, 3=severe

Less reactive to visual (sights) or auditory (sounds) stimuli
0
1
2
3
Score as 0=none, 1=mild, 2=moderate, 3=severe

More irritable / fearful / aggressive with visitors, family, or other animals
0
1
2
3
Score as 0=none, 1=mild, 2=moderate, 3=severe

Decreased interest in approaching, greeting or affection / petting
0
1
2
3
Score as 0=none, 1=mild, 2=moderate, 3=severe

Pacing / restless / sleeps less / waking at night
0
1
2
3
Score as 0=none, 1=mild, 2=moderate, 3=severe

Vocalization at night
0
1
2
3
Score as 0=none, 1=mild, 2=moderate, 3=severe

Less able to learn new tasks or respond to previously learned commands / name / work.
0
1
2
3
Score as 0=none, 1=mild, 2=moderate, 3=severe

Indoor soiling of urine or stool / decreased signaling to go out
0
1
2
3
Score as 0=none, 1=mild, 2=moderate, 3=severe

Decrease in exploration or play with toys, family members, other pets
0
1
2
3
Score as 0=none, 1=mild, 2=moderate, 3=severe

Increased activity including aimless pacing or wandering
0
1
2
3
Score as 0=none, 1=mild, 2=moderate, 3=severe

Repetitive behaviors, e.g. circling, chewing, licking, or "star gazing"
0
1
2
3
Score as 0=none, 1=mild, 2=moderate, 3=severe

Increased anxiety when separated from owners
0
1
2
3
Score as 0=none, 1=mild, 2=moderate, 3=severe

More reactive / fearful to visual (sights) or auditory (sounds) stimuli
0
1
2
3
Score as 0=none, 1=mild, 2=moderate, 3=severe

Increased fear of places / locations (e.g. new environments / going outdoors)
0
1
2
3
Score as 0=none, 1=mild, 2=moderate, 3=severe

DISHAA Cognitive Final Score

Mobility Assessment of Older Dogs

For a Life Stage exam, we would like to assess your dog’s activities and behaviors that may be signs of osteoarthritis.

Do I want to evaluate and discuss my older dog's mobility with a quick checklist?
Yes, I would like to complete a quick checklist
No, I just want to finish these questions

Dog Mobility Assessment - please select all that apply
Limping after exercise
Lagging behind on walks
Slow to rise
Difficulty jumping
Feeling stiff
Difficulty with stairs

Are your pet's housemates current with their preventative care?
Yes, housemates have been seen by a veterinarian within last 12 months for preventative care
I am actually bringing in this housemate at this same visit for care.
No, housemates are not current and I am not interested in scheduling such care for them at this time.
No, housemates are not current and I would like to schedule them for preventative care. Please contact me.

Technician Office Visit

Your pet will be taken care of by a support personnel and not by a doctor at this visit. Due to the current high demand for all veterinary visits, you may have to wait a short time for a team member to become available, an exam room may not be available, and-or your time will be limited to 5 to 15 minutes.

Requested Services
Vaccination or immunization
Suture removal
Laboratory test(s)
Diabetes support
Nutritional consultation
Bandage change or removal
Nail trim
Anal gland expression
Other request

Other requested service for Technician Visit

Is your pet eating and / or drinking normally?
Yes
No

Is your pet having normal bowel and urine habits?
Yes
No

If not, describe issue:

Medical Progress Exam

How has your pet's condition changed since last visit?

Describe your pet's response to any medications dispensed.

Additional comments you would like to share
- additional comments -

Pre-Surgery Exam

The purpose of a "Pre-Surgery Exam" is to rule in / out any 'surprises' the day of the procedure(s). We want to address, before the procedure, conditions like hernias that should be repaired, retained baby teeth, tear ducts to flush, and undescended testicles. Also, blood is to be drawn for the pre-anesthetic screen so a proper, customized anesthesia plan unique to your pet, can be prepared in advance.

Which surgery are you interested in?
Spay
Neuter
Hernia repair
A different or additional surgery at the same time

Is the adult weight of your dog expected to be 70 pounds or more?
Yes, I have a large or giant breed dog.
No, the adult weight of my dog is expected to be less than 70 lbs.

Large breed dogs are susceptible to developing a swelling and twisting of their stomach. This becomes a life threating emergency that has to be surgically addressed in a matter of a few hours. A gastropexy is where we proactively tack the stomach wall to the side of the abdominal wall to prevent it from twisting in the future. For more information, visit GDV and Gastropexy

Please check if your dog is currently on the following preventative medications:
Heartworm prevention
Flea and Tick prevention

Current Medications or Supplements Your Pet is Receiving- none -

Follow up Test or Procedure with Doctor

No additional questions for you at this time. We will see you at your scheduled visit

Coughing & / or Sneezing

My pet is showing the following symptom(s):
Coughing
Sneezing
Nose discharge
Eye discharge

Does your pet's cough produce any material?
Yes, the cough is producing material
No, the cough is not productive

Describe the material that is coughed out:

Approximately, how long ago did you first notice symptoms?

How have the symptoms changed since you first noticed them?

Has your dog been boarded within last two weeks?
Yes
No

Is your pet's energy level decreased?
Yes, the energy level is decreased
No, my pet's energy level is normal

Is your pet's energy appetite decreased?
Yes, the appetite level is decreased
No, my pet's appetite is normal

Besides parasite prevention, is there any medications or supplements your pet is taking?

Anything else you would like to us to know?

Although it is up to the examining doctor's discretion, generally we may be recommending (not requiring) that chest x-rays be taken for coughing pets.

Ear(s) Problems

Which ears seem to be affected?
Both ears
Left ear
Right ear

Approximately how long ago was ear(s) problem first noticed?

How has the ear(s) problem changed since you first noticed?

Describe any medications you have already tried to heal the ear(s).

If you have tried to clean the ear(s), describe your method of cleaning

Has your pet been previously diagnosed or suspect to have allergies?
Yes, allergies diagnosed or suspected
No previous allergy diagnosis

Besides parasite prevention, is there any medications or supplements your pet is taking?

Is there anything else you would like to us to know?

Although it is up to the examining doctor's discretion, generally we may be recommending (not requiring) that a sample of ear debris be collected for cytology evaluation

Eye(s) Problems

Which eyes seem to be affected?
Both eyes
Left eye
Right eye

Approximately how long ago was eye(s) problem first noticed?

How has the eye(s) problem changed since you first noticed?

Is there any itching or rubbing of the affected eye(s)?
Yes, my pet is itching or rubbing the eye(s).
No, my pet's is not itching nor rubbing the eye(s)

Is there any squinting or "winking" of the affected eye(s)?
Yes, my pet is squinting or 'winking' of the affected eye(s).
No. My pet's is not squinting or 'winking' of the eye(s)

Is there any abnormal discharge affected eye(s)?
Yes, there is an abnormal eye discharge.
No. There is no abnormal eye discharge

Any change in appetite?
Yes, there is a change in appetite
No. There is no change in my pet's appetite.

My pet's appetite is:
decreased.
increased.

Is there a change in your pet's energy level?
Yes, my pet is less active
Yes, my pet is more active
No. There is no change in energy level.

Are there any other pets in the home with similar symptoms?
There are no other pets in the home
No. There are other pets but they are not affected yet
Yes. There are pets in the home with similar symptoms.

Besides parasite prevention, is there any medications or supplements your pet is taking?

Is there anything else you would like to us to know?

Limping

Which limb(s) seem to be affected?
Left front leg
Right front leg
Left rear leg
Right rear leg

Is the lameness constant or intermittent?
Constant lameness
Intermittent or periodic lameness

Approximately how long ago was the lameness first observed?

What was the onset of the lameness?
Sudden lameness
Gradual onset of lameness

Any known injuries?
Yes, known injury
No known injury or incident

Describe injury or incident that may have caused lamness.

Any known exposures to 'deer' ticks?
Yes, known exposure to deer ticks
No known exposure to deer ticks

Describe any changes to the lameness since first noticed.

Besides parasite prevention, is there any medications or supplements your pet is taking?

Anything else you would like to us to know?

Although it is up to the examining doctor's discretion, generally we may be recommending (not requiring) that x-rays be taken as part of the evaluation.

Skin Growth &or Tumor &or Swelling Questions

Which area(s) of the body seem to be affected?

Approximately when were the skin problem(s) first observed?

How have the skin problem(s) changed since you first observed?

Although it is up to the examining doctor's discretion, generally we may be recommending (not requiring) that a tissue sample be collected for a preliminary exam called a "Fine Needle Aspirate", which is not a biopsy.

Besides parasite prevention, is there any medications or supplements your pet is taking?

Anything else you would like to us to know?

Skin Issue &or Hair Loss &or Itchy Questions

Which symptom(s) is your pet showing?
General skin issue
Hair loss
Itchiness scratching

Approximately when did the skin problem begin?

How has the skin problem changed since you first noticed it?

Has your pet been diagnosed or suspected to have allergies in the past?
Yes, history of allergies or suspected allergies in the past
No known history of allergies
I am unsure

Any other pets in the home affected by a similar skin problem?
Yes, another pet has similar skin problem(s)
No other pets in the home affected

Any human family members have any recently acquired skin rashes or itchiness?
No recent skin issues with human family members
Yes, there have been recent new skin issues with our family

Please briefly describe these new human skin issues

Although it is up to the examining doctor's discretion, generally we may be recommending (not requiring) that a small area of surface be evaluated for mites. This is called a "Skin Scraping".

Besides parasite prevention, is there any medications or supplements your pet is taking?

Anything else you would like to us to know?

Vomiting &or Diarrhea Questions

Which symptom(s) is your pet currently showing?
Vomiting
Diarrhea

Approximately when did the symptom(s) start?

How have the symptoms changed since you first observed them?

Any changes to thirst or appetite?
Yes, changes with thirst or appetite
No changes with thirst or appetite

Is your pet's energy level normal?
Yes, normal energy level
No decreased energy observerd.

Did your pet eat anything it should not have that you are aware of?
Yes, my pet ate something not supposed to eat
No, as far as I know, heshe did not anything abnormal.

Describe what your pet ate that it should not have?

What does the vomitus look like? Ex. color, food in it, bile.

How frequent is the vomiting occurring?

Approximately how long ago was the last known time your pet vomited?

Anything missing the home your pet may have swallowed?
Yes, there is something missing
No, I am unaware of anything missing in the home my pet may have eaten.

Describe what may have been swallowed.

Although it is up to the examining doctor's discretion, generally we may be recommending (not requiring) that vomiting pets have abdominal x-rays performed

Describe the consistency of the diarrhea

How frequent is the diarrhea occurring?

Any defecation accidents inside the house?
Yes, my pet is defecating inside the house
No, my pet has not had defecation accidents inside the house

Is there any mucous or blood in the feces?
Yes, there is blood or mucous in the feces
No, there is not any observed blood or mucous in the feces
I am not certain if there blood or mucous in the feces.

Although it is up to the examining doctor's discretion, generally we may be recommending (not requiring) that pet's with diarrhea have an intestinal parasite screening performed. Please bring in a small feces sample (just 1" in length or approximately 1 tablespoon).

Besides parasite prevention, is there any medications or supplements your pet is taking?

Anything else you would like to us to know?

Lethergy &_or Decreased Activity

Please select all observations that apply:
increased lethargy or quietness
decreased activity
decreased appetite
increased appetite
No observed change in appetite
increased water consumption
decreased water consumption
weight loss
increased vomiting frequency
increased or worsening diarrhea

Approximately how long ago were the symptoms first observed?

How has issue(s) changed since first noticed

Did your pet eat anything it should not have that you are aware of?
Yes, my pet ate something not supposed to eat
No, as far as I know, heshe did not anything abnormal.

Describe what your pet ate that it should not have?

Any new or changes to preexisting tumors or growths?
No
Yes

Please describe these changes of tumors or growths

Any known tick exposure?
No known tick exposure
Yes

Any known toxin or poison exposure?
No known toxin nor poison exposure
Yes
I already answered a few questions ago

Please describe toxin or poison exposure (what, which brand, what is the concentration, when, and your best estimate as to how much)

Is there anything else you would like us to know?

Besides parasite prevention, is there any medications or supplements your pet is taking?

Although it is up to the examining doctor's discretion, generally we may be recommending (not requiring) that lethargic pets have a blood chemistry panel performed if the exam and the history are unremarkable. This is to help us identify where the source of the lethargy may be.

Behavior - Aggression Towards Other Pets Questions

Aggression in pets can be due to guarding territory, resources availability, or a family member; fear; frustration; prey drive; or even pain. Aggression is NOT due to your pet being "mean".

Please check all that apply. My pet can be aggressive towards:
Other cat(s) in home
Cats outside of home, unfamiliar cats
Other dog(s) in home
Humans

Is it a particular individual pet or several other pets or other animals in general?
Aggression is directed only at another individual pet
Aggression is directed at several other pets in our home
Aggression is directed at other pets outside of home

Describe the events surrounding the aggression the best you can

Has there been any injuries to other pets?
Yes, there has been at least one injury.
No known injuries to other pets

Are there any known injuries to other pets?
Yes, there has been at least one injury.
No known injuries to other pets

How many rooms have litter boxes in them?

How many rooms are used as a feeding area?

Are there elevated spaces available? For example, cat towers cat trees or ledges.
Yes, there are elevated spaces available
No there are no elevated spaces available other than counter tops or table tops

Is there anything else you would like us to know?

Besides parasite prevention, is there any medications or supplements your pet is taking?

Behavior - Inappropriate Urination or Defecation Questions

Please select all that apply. There is inappropriate:
Urination
Defecation

Is there a corresponding noticeable increase in water consumption?
Yes, my pet is drinking more water
I believe my pet is drinking normal volumes of water
I am uncertain if my pet is drinking more water or not

Which best describes the texture of the feces?
The feces are of normal texture
The feces are smaller and firmer than normal
The feces are looser than normal, softer
I am uncertain as to feces texture currently is

Do you know for certain which pet in the home is eliminating inappropriately?
Yes, I know for certain
No. I am uncertain which pet may be eliminating inappropriately.

Approximately when did the behavior start?

How has the behavior changed since you first noticed it?

Describe the behavior, including your cat’s body position, while eliminating.

What times of day and where in the home does the behavior happen now?

List any changes in the home associated with the appearance of the behavior.

How frequently does the behavior happen? (for example, how many times per day, weeks, or per month?)

How many total cats are in the home?

Do see the cats in the home grooming each other or napping together?
Yes, they groom or nap together
No, I do not see them grooming nor napping together
Maybe, I uncertain if they do or do not

How many litter boxes are in the home?

How many rooms have litter boxes in them?

Are there litter boxes on all of the levels?
Yes, litter boxes on all levels
There are litter boxes on more than one level but not all
Litter boxes on only one level

Describe in more detail where the litter box(es) are located within the home

Are the litter box(es) covered or uncovered?
Yes, all are covered
Some are covered, some uncovered
No covers on any of the boxes

Are the litter boxes commercially available or are they custom made?
All are commercially available
Some or all boxes are custom made

Describe the custom made litter box(es)

Is there anything else you would like us to know?

Besides parasite prevention, is there any medications or supplements your pet is taking?

Behavior - general fear & anxiety questions

What is or are the primary anxiety behavior(s) displayed?

Approximately how long ago did these behavior symptoms first appear?

How have these behavior symptoms changed since first noticed?

What medications or supplements have you tried? (Describe duration of administration and effectiveness), if any)

Is there anxiety with loud noises? (Examples, thunder or fireworks)
Yes, anxiety to loud noises
No anxieties to loud noises

Is there any destruction to the home when you are away?
Yes, home destruction when alone
No home destruction observed

Describe any changes in the home that you feel may be contributing to the behavior

Besides parasite prevention, is there any medications or supplements your pet is taking?

Is there anything else you would like us to know?

Besides parasite prevention, is there any medications or supplements your pet is currently taking?

Behavior - separation anxiety &_or fear of loud noises

I am concerned my pet is anxious or fearful: (check all that apply)
Being separated from human family
Being separated from other pet housemates
Fearful or anxious about Thunder
Fearful or anxious about fireworks

How does your pet behave when left alone as far as you know?

Describe how your pet reacts when you get ready to leave the house.

Does your dog ever growl at you or act aggressively when you leave the house?
Yes
No

Describe this behavior best you can

Does your pet exhibit this behavior each time that you depart?
Yes
No

How long does it take for your pet to calm down when you return?
less than 5 minutes
5 to 10 minutes
10 to 15 minutes
more than 15 minutes

When you are home and your dog is confined away from you at home, how does he/she react?

What is your pet’s reaction to being placed in the crate or kennel or carrier?

What is your pet’s reaction to loud noises and thunderstorms?
Calm and relaxed
Somewhat anxious but we manage
Gets highly anxious and fearful

Describe what you have tried to do in the past, training or medications, and their effects

How would you rate the severity of your pet’s problem?
Mild
Moderate
Severe
Very Severe

Is there anything else you would like us to know?

Besides parasite prevention, is there any medications or supplements your pet is currently taking?

Drinking more water &_or Urinating Larger Volume

Please select all observations that apply:
More water being consumed
Increased urine volume produced
Decreased appetite
Increased appetite
No observed change in appetite

Approximately how long ago was the problem(s) first observed?

How has issue(s) changed since first observed?

Please provide any additional comments with your concern(s):

Any known tick exposure?
Yes
No known exposure

Please select those activities your dog does?
explore outdoors
hunts
stays at a cabin
visits dog parks

Is there anything else you would like us to know?

Besides parasite prevention, is there any medications or supplements your pet is taking?

Although it is up to the examining doctor's discretion, generally we may be recommending (not requiring) that pet's drinking more or urinating more a urine analysis. Try to keep your pet from urinating for a few hours before the scheduled exam time.

Decreased Appetite &_or Weight Loss

Please select all observations that apply:
decreased appetite
weight loss
increased lethargy or quietness
decreased activity
No observed change in appetite
increased water consumption
decreased water consumption
increased vomiting frequency
increased or worsening diarrhea

Approximately how long ago were the symptoms first observed?

How has issue(s) changed since first noticed?

Any known tick exposure?
No known tick exposure
Yes

Is there anything else you would like us to know?

Besides parasite prevention, is there any medications or supplements your pet is taking?

Travel Health Certificates

Complete this worksheet BEFORE meeting with the USDA Accredited Veterinarian who needs this information to complete your international health certificate. As soon as you know your travel details, contact us to assist with the pet travel process. Factors to consider may include visit time frames for obtaining a health certificate, updating vaccinations, diagnostic testing, or administration of medications/ treatments.. Follow the hyperlink below to be taken to the USDA / APHIS information page regarding pet travel.

Link to USDA / APHIS Pet Travel Information

Where traveling to?
International
Between states within the US

Address
Address Line 1
Address Line 2
City
State
Zip Code

Which state are you traveling to?

Who is accompanying your pet(s) while traveling?
An owner
A person authorized by the owner
A pet transport company
Nobody

Destination Date Arrival (estimated)

If known, what is the US domestic address your pet(s) is traveling to?
Address Line 1
Address Line 2
City
State
Zip Code

If known, what is the phone number of your pet's US destination?

Which countries will your pet(s) be traveling to?

How many international destinations will your pet(s) have?
One destination
Two destinations
Three destinations
Four destinations

If known, what is the international address your pet(s) is traveling to? [Address #1]
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Country

If known, what is the phone number of your pet's international destination? [Phone #1]

If known, what is the international address your pet(s) is traveling to? [Address #2]
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Country

If known, what is the phone number of your pet's international destination? [Phone #2]

If known, what is the international address your pet(s) is traveling to? [Address #3]
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Country

If known, what is the phone number of your pet's international destination? [Phone #3]

If known, what is the international address your pet(s) is traveling to? [Address #4]
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Country

If known, what is the phone number of your pet's international destination? [Phone #4]

How is your pet(s) departing the US?
Air - Direct Flight
Air - Indirect Flight, Layovers in other countries
Car
Train
Boat - Direct trip
Boat - Indirect trip, stops in additional countries

Please list additional countries where the airline layover(s) will be

Please list the additional countries where the boat stops will be

Which pet's will be traveling? If we have seen your pet within the last year, you just need to list their name. If we have NOT seen your pet before nor within the last year, we will need the pet's name, species, age, and weight.

Has your pet been seen by a different veterinary care provider within the last year for preventative care?
Yes, my pet(s) has been seen by another care provider in the last year
No, my pet(s) have not been seen by another care provider recently

Please convey any contact information for that care provider so we may get records.

Do all of the pets traveling have microchips under their skin?
Yes, they all have microchips
Only some of them have microchips
None of them have microchips
I do not know

If we have seen the pet's traveling before, we should have microchip information and you do not have to complete this question. If we have not seen your pet(s) before, please list the pet's name along with their microchip number from their medical records.

Did your airline or boat (example, cruise ship) give you any additional travel requirements for your pet?
Yes, I will deliver this information to you well in advance of our appointment
No, I know there are no additional requirements
I do not know. I will contact my airline or boat to see if there is any additional requirements and then contact you again.

Quality of Life or Euthanasia or Cremation Request

What are your primary reason(s) for scheduling? Check all that apply
A quality of life discussion with a doctor as I have not yet decided euthanasia
Euthanasia, I know I want this humane procedure for my loved one.
Cremation

Have we seen your pet within the last 12 months?
Yes, you have seen my pet within the last 12 months and for the medical concerns affecting my pet
Yes, you have seen my pet within the last 12 months but not fot the medical concerns affecting my pet
No, you have never seen my pet
No, it has been more than 12 months since you have seen my pet

Do you want to be present for the euthanasia procedure?
Yes, I would like to be present for the euthanasia
No thank you. I am not interested in having myself nor family members present

Have you been present during a pet euthanasia in the past?
Yes, I have been present for a euthanasia
No this will be my first time experiencing a euthasia.

Our sympathies go to you and any family members at this difficult time. We understand you are making this tough decision for the welfare of your pet over your own.

Our goal is to make this as easy as is possible for your pet. Euthanasia, is essentially, an overdose of a concentrated anesthetic, so your pet becomes anesthetized first, unaware of his or her environment before the heart stops.

Cremation choice
I do not want my pet cremated. I want to take him or her home after the procedure
I have already discussed my cremation options with the clinic.
Yes, I would like to know what my cremation options are.

Since cremation options change frequently, for your most current options call us at one of locations.

Second Opinion Examination and Consult

To provide a higher level of care and get a more complete picture of what is happening, we ask that we receive a copy of your pet's recent complete medical record, example tests run and therapies attempted. Whom may we contact?
I do not want you to contact a my existing or previous care provider.
Yes, you have permission to contact my existing or previous care provider

My existing or previous care provider is:

What is your concern with your pet? Please include when the problem was first observed and how has the problem changed.

Besides parasite prevention, is there any medications or supplements your pet is taking?

Other, Not Previously Listed Concern I Have

We can't possibly cover all conditions and/or concerns an owner may have in a form. If you do not see your concern listed, please do so here

When was the concern first noticed?

How has the concern changed since noticed?

Describe your concern

Besides parasite prevention, is there any medications or supplements your pet is taking?

History Intake Form

Scheduled Surgery or Dentistry Care

Behavior Assessment of Older Cats

Behavior Assessment of Older Dogs

Mobility Assessment of Older Dogs

Technician Office Visit

Medical Progress Exam

Pre-Surgery Exam

Follow up Test or Procedure with Doctor

Coughing & / or Sneezing

Ear(s) Problems

Eye(s) Problems

Limping

Skin Growth &or Tumor &or Swelling Questions

Skin Issue &or Hair Loss &or Itchy Questions

Vomiting &or Diarrhea Questions

Lethergy &_or Decreased Activity

Behavior - Aggression Towards Other Pets Questions

Behavior - Inappropriate Urination or Defecation Questions

Behavior - general fear & anxiety questions

Behavior - separation anxiety &_or fear of loud noises

Drinking more water &_or Urinating Larger Volume

Decreased Appetite &_or Weight Loss

Travel Health Certificates

Quality of Life or Euthanasia or Cremation Request

Second Opinion Examination and Consult

Other, Not Previously Listed Concern I Have

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