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Appointment Check In Sheet

Owner Full Name:

*

Pet's Name:

*

Phone Number:

*

If you have any concerns, how long have they occurred?

Is your pet experiencing any of the following:

*

Vomitting?

Is your pet experiencing any of the following:

Yes

No

Diarrhea?

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Yes

*

No

Coughing?

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Yes

*

No

Sneezing?

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Yes

*

No

Changes in thirst?

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Yes

*

No

If yes, increase or decrease?

*

Changes in urination?

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Yes

*

No

If yes, increase or decrease?

*

Changes in appetite?

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Yes

*

No

If yes, increase or decrease?

*

Weight changes?

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Yes

*

No

If yes, weight loss or gain?

*

Changes in behavior?

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Yes

*

No

Any injuries?

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Yes

*

No

For Dogs Only:

*

Lagging on Walks?

For Dogs Only:

Yes

No

Slow to get up?

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Yes

*

No

Any difficulty jumping?

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Yes

*

No

Stiffness when walking?

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Yes

*

No

Resistance to using the stairs?

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Yes

*

No

For Cats Only:

*

Resistance to jumping up or down?

For Cats Only:

Yes

No

Resistance to climbing up or down?

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Yes

*

No

Less interest in playing or chasing objects?

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Yes

*

No

Moving slower?

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Yes

*

No

Any changes in litter box habits?

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Yes

*

No

Is your cat

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Indoor?

*

Outdoor?

Both?

Did you bring a fecal sample today?

*

Did you bring a fecal sample today?

A

Yes

B

No

Anything else you would like to address today? (nail trim, anal glands, etc.)

*

Anything else you would like to address today? (nail trim, anal glands, etc.)

Nail trim

Anal gland expression

Other

Please list your pet’s diet, amount, and frequency of feeding:

*

Do you need any refills of heartworm and flea/tick preventatives?

*

Do you need any refills of heartworm and flea/tick preventatives?

A

Yes

B

No

Is your pet on any medications/supplements?

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Yes

*

No

If yes, please list the medications:

*