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APPOINTMENT CHECK-IN SHEET

Pet Name:

*

Please state the reason for your visit and how your pet is doing:

*

Is your pet experiencing any of the following:

*

Vomiting?

Is your pet experiencing any of the following:

A

Yes

B

No

Diarrhea?

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A

Yes

*

B

No

Coughing?

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A

Yes

*

B

No

Changes in thirst?

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A

Yes

*

B

No

If yes, increase or decrease?

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A

Increase

*

B

Decrease

Changes in urination?

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A

Yes

*

B

No

If yes, increase or decrease?

C

Increase

D

Decrease

Changes in appetite?

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A

Yes

*

B

No

If yes, increase or decrease?

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A

Increase

*

B

Decrease

Weight changes?

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A

Yes

*

B

No

If yes, weight loss or gain?

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A

Loss

*

B

Gain

Changes in behavior?

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A

Yes

*

B

No

Any injuries?

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A

Yes

*

B

No

FOR DOGS:

Lagging on walks?

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A

Yes

*

B

No

Slow to get up?

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A

Yes

*

B

No

Difficulty jumping?

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A

Yes

*

B

No

Stiffness when walking?

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A

Yes

*

B

No

Resistance to using the stairs?

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A

Yes

*

B

No

FOR CATS:

Resistance to jumping up or down?

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A

Yes

*

B

No

Resistance to climbing up or down?

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A

Yes

*

B

No

Less interest in playing or chasing objects?

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A

Yes

*

B

No

Moving slower?

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A

Yes

*

B

No

Has personality or sociability changed?

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A

Yes

*

B

No

Any changes in litter box habits?

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A

Yes

*

B

No

Did you bring a fecal sample today?

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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?

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A

Yes

*

B

No

Do you need refills?

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A

Yes

*

B

No

Is your pet on any medications/supplements?

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A

Yes

*

B

No

If yes, please list the names and when they were last given:

*

Do you need refills on any?

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A

Yes

*

B

No

If yes, please list the medications:

*