Check-In FormCheck In Form Step 1 of 333%CHECK-IN INFORMATIONIn an effort to minimize exposure due to COVID-19 for our clients and staff, we would like to ask that you pre-fill out this brief questionnaire to maximize information about your pet's visit today. We appreciate your patience, look forward to seeing your pet and also talking with you shortly.Please select the primary reason you are bringing your pet in today from the options below. If your pet has an issue today that is not listed here, please refer to the box at the end of this documentYour Name:*Your Pet's Name:*Annual ExamAny issues or concerns today?*YesNoPleas Explain:*Is your pet on heartworm prevention monthly?*YesNoIs your pet on flea/tick prevention monthly?*YesNoWhat are you currently feeding your pet?*Are you giving any supplements or over the counter medications? If so, which ones and how much?*Vomiting/diarrheaWhen did symptoms start?How Long?What are you seeing? (foam, whole food, blood, bile, etc)Did you bring samples today?YesNoDid you administer any over the counter medications? If so, when and what was the outcome?Is there any other history you would like to add today? (ie, ingestion of toxin, new diet, ingestion of non-food items, etc)Still Eating/drinking?YesNoWhat at this time? CoughingHow Long?Can you describe the type of cough?When does your pet primarily cough (with exercise, sleeping, etc)Indoor/outdoor or both?IndoorOutdoorBothOn heartworm prevention monthly?YesNoHistory of any heart issues (murmur, arrhythmia, etc.?)Recently boarded or groomed?YesNoIs there any other history you would like to add today?Skin/Ear problemsHow Long?Which areas are affected most?How itchy is your pet on a scale of 1-10 (10 being the worst)?Did you administer any medications? If so, when and what was the outcome?What are you currently feeding your pet (food and treats)?What do you currently use for flea and tick prevention? How often do you administer this prevention?Is anyone else in the home scratching/itching (human or animal)?Is there any other history you would like to add today? Limping/painWhen did symptoms start?How Long?Do you know of any trauma or physical injury that may have occurred?Which parts of the body do you feel are affected?Still eating/drinking?YesNoDid you administer any over the counter medications? If so, when and what was the outcome?Other problem not listed here:Please briefly explain your pet's current issue.Any additional services, products or refills on medications requested?We thank you again for your patience in helping us and you stay safe while we care for your pets. Please forward this to our front desk before your appointment or you can print this out and give this to an assistant when you come for your appointment. Thank you!