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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
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Cell Phone Number
*
Please enter the number of the cell phone you will be having with you for your appointment
Patient Information
Pet Name
*
Pet's Name
Date of birth
*
MM
DD
YYYY
If you are not sure about your pets birthday, please select an age close to your pets age
Species
*
Dog
Cat
Other
Breed/Color
*
Cats
Indoor only
Outdoor only
Indoor/Outdoor
Where does your feline pet reside?
Sex
*
male
female
male/altered
female/altered
Date
*
MM
DD
YYYY
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.
Reason for visit
*
Please describe your concerns
Coughing
*
Yes
No
Any coughing? If yes, when did it start and how often do they cough?
If answered yes, please explain
Sneezing
*
Yes
No
Any sneezing? If yes, when did it start? Is there any nasal discharge? If yes, what color?
If answered yes, please explain
Vomiting?
*
Yes
No
Any vomiting? If yes, when did it start and how frequently are they vomiting?
If answered yes, please explain
Diarrhea
*
Yes
No
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?
If answered yes, please explain
Bowel Movement
When was the last time you saw your pet have a bowel movement and what did it look like?
Drinking
*
Yes
No
Any change in how much water your pet is drinking? If yes, are they drinking more or less water and when did it start?
If answered yes, please explain
Urination
*
Yes
No
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?
If answered yes, please explain
Appetite
*
Increased
Normal
Decreased
Has your pet’s appetite changed and if so describe how? When did they last eat? How long is this been going on?
If answered yes, please explain
Diet Changes
*
Yes
No
Any change in diet? If yes, when and what did you change? What are you currently feeding your pet?
If answered yes, please explain
Energy
*
Yes
No
Is your pet lethargic (not active)? If yes, how long?
If answered yes, please explain
Orthopedic
*
Yes
No
Is your pet here because it is limping? If yes, which leg and how long?
If answered yes, please explain
Pain
*
Yes
No
Has your pet cried out? If yes, what was your pet doing when this occurred?
If answered yes, please explain
Eyes
*
Yes
No
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?
If answered yes, please explain
Ears
*
Yes
No
Does your pet have a problem with one or both of its ears? If yes, which ear and describe any discharge or symptoms?
If answered yes, please explain
Teeth
*
Yes
No
Do you have any concerns with your pet’s teeth? If yes, describe concerns.
If answered yes, please explain
Skin
*
Yes
No
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?
If answered yes, please explain
Behavior
*
Yes
No
Have you seen any behavior changes? If yes, please describe the changes.
If answered yes, please explain
Please list all medications/supplements your pet is currently taking and when they were last given:
Home
About Us
Location & Hours
Our Veterinarians
Our Care Team
Office tour
Contact
Services
Preventative Health Care
Diagnostic/Laboratory
Dental Services
Surgical Services
Exotic Health Care
Additional Services
Medical Services
Pet Care
Patients
Forms
Payment Options
Pet Health
Pet Health Library
Pet Health Checker
Pet Insurance Info
News
New Clinic Updates
Fear Free
Pharmacy