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APPOINTMENT CHECK-IN SHEET
Owner Name
*
Owner Phone Number
*
Pet Name:
*
Please state the reason for your visit and how your pet is doing:
*
Is your pet experiencing any of the following:
Vomiting
*
Vomiting
A
Yes
B
No
Diarrhea
*
Diarrhea
A
Yes
B
No
Coughing
*
Coughing
A
Yes
B
No
Sneezing
*
Sneezing
A
Yes
B
No
Changes in thirst
*
Changes in thirst
A
Yes
B
No
If yes, increase or decrease?
If yes, increase or decrease?
A
Increase
B
Decrease
Changes in urination
*
Changes in urination
A
Yes
B
No
If yes, increase or decrease?
If yes, increase or decrease?
A
Increase
B
Decrease
Changes in Appetite
*
Changes in Appetite
A
Yes
B
No
If yes, increase or decrease?
If yes, increase or decrease?
A
Increase
B
Decrease
Weight Changes?
*
Weight Changes?
A
Yes
B
No
If yes, weight loss or gain?
If yes, weight loss or gain?
A
Loss
B
Gain
Changes in behavior
*
Changes in behavior
A
Yes
B
No
Any injuries?
*
Any injuries?
A
Yes
B
No
FOR DOGS
:
Lagging on walks?
*
Lagging on walks?
A
Yes
B
No
Slow to get up?
*
Slow to get up?
A
Yes
B
No
Difficulty jumping?
*
Difficulty jumping?
A
Yes
B
No
Stiffness when walking?
*
Stiffness when walking?
A
Yes
B
No
Resistance to using the stairs?
*
Resistance to using the stairs?
A
Yes
B
No
FOR CATS:
Resistance to jumping up or down?
*
Resistance to jumping up or down?
A
Yes
B
No
Resistance to climbing up or down?
*
Resistance to climbing up or down?
A
Yes
B
No
Less interest in playing or chasing objects?
*
Less interest in playing or chasing objects?
A
Yes
B
No
Moving slower?
*
Moving slower?
A
Yes
B
No
Has personality or sociability changed?
*
Has personality or sociability changed?
A
Yes
B
No
Any changes in litter box habits?
*
Any changes in litter box habits?
A
Yes
B
No
Anything else you would like to address today? (nail trim, anal glands, etc.)
*
Please list your pet’s diet (brand), amount, and frequency of feeding:
*
Is your pet current on heartworm and flea/tick preventatives?
*
Is your pet current on heartworm and flea/tick preventatives?
A
Yes
B
No
Do you need refills?
*
Do you need refills?
A
Yes
B
No
Is your pet on any medications/supplements?
*
Is your pet on any medications/supplements?
A
Yes
B
No
If yes, please list:
Do you need refills on any?
*
Do you need refills on any?
A
Yes
B
No
If yes, please list:
Submit
