Curbside Medical History Form

Please have this form completed before coming to the hospital. You can email it back before your appointment or bring it with you. Your pet will be brought into the hospital by a team member, the doctor will do an exam and answer any questions/conversations by phone. Please have your cell phone ready and the number of that phone on this form. Payment services will be curbside as well, and expected after the visit is complete.
  • Client Information

  • Please enter the number of the cell phone you will be having with you for your appointment
  • Patient Information

  • Pet's Name
  • If you are not sure about your pets birthday, please select an age close to your pets age
    Where does your feline pet reside?
  • Please enter todays date
  • Please arrive 10 minutes before your appointment time. You may park in the parking lot on the east side of our hospital. If your pet is scheduled for routine annual exam / vaccinations, we also recommend yearly bloodwork and stool sample checks
  • Please call our office once you have arrived. 785-823-2217 Please let us know the make, color and model of your car. If you have any respiratory symptoms, fever and/or cough, have traveled recently or are in quarantine/had contact with anyone that may have coronavirus, please be sure to let our staff answering the phone know!
  • Please have your pet on a leash or in a carrier before we come to the car. Please bring a stool sample, so if needed it is available.
  • Medical History Questions

  • Briefly describe the reason your pet is here for an exam, such as ear infection, sick or limping. Please answer all questions below regardless of why your pet is here.
  • Please describe your concerns
    Any coughing? If yes, when did it start and how often do they cough?
    Any sneezing? If yes, when did it start? Is there any nasal discharge? If yes, what color?
    Any vomiting? If yes, when did it start and how frequently are they vomiting?
    Any diarrhea? If yes, when did it start and how often are they having diarrhea? Please describe the consistency. Does your pet’s stool look normal in color? If no, is it black or bloody?
  • When was the last time you saw your pet have a bowel movement and what did it look like?
    Any change in how much water your pet is drinking? If yes, are they drinking more or less water and when did it start?
    Is the patient urinating as he/she normally does? If no, when did it start and is he/she urinating more or less? Have you seen your pet’s urine? If so what was the color and amount?
  • Has your pet’s appetite changed and if so describe how? When did they last eat? How long is this been going on?
    Any change in diet? If yes, when and what did you change? What are you currently feeding your pet?
    Is your pet lethargic (not active)? If yes, how long?
    Is your pet here because it is limping? If yes, which leg and how long?
    Has your pet cried out? If yes, what was your pet doing when this occurred?
    Does your pet have a problem with one or both of its eyes? If yes, which eye and describe any drainage or symptoms? How long has this been going on?
    Does your pet have a problem with one or both of its ears? If yes, which ear and describe any discharge or symptoms?
    Do you have any concerns with your pet’s teeth? If yes, describe concerns.
    Are there any new lumps or bumps you have found? If yes, where are they and how long have they been present? Have they changed in size?
    Have you seen any behavior changes? If yes, please describe the changes.