(888) 788-1165
(888) 788-1165
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Monday - Friday 8:00 AM - 7:00 PM | Saturday 10:00 AM - 4:00 PM | Sunday Closed
Appointment Protocols
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(888) 788-1165
support@bettervet.com
support@bettervet.com
About Us
Our Team
Gallery
Testimonials
Pet Services
Vaccines
Microchipping
Dentistry
Surgery
Geriatric Care
Hospice
In-Home Euthanasia
Euthanasia Release
Diagnostics
Cold Laser Therapy
Ultrasound & X-Rays
New Owner Consultations
Behavior Consultations
Nutritional Consultations
Health Certificates
Sick Pet Visits
Emergencies
New Clients
Online Store
Resources
Blog
Urine and Stool Samples
Referrals
Contact Us
Pre-Visit Questionnaire
Client Name
*
Pet Name
*
Upcoming Visit Date
*
Please list your concerns regarding your pet’s health and the reason(s) for your upcoming at-home visit.
*
Is this a recheck visit and/or has your pet been seen by one of our doctors within the past 2 months?
Yes
No
Have there been any changes and/or new concerns?
Yes
No
Please indicate changes and/or new concerns below
Vomiting?
Diarrhea?
Coughing?
Sneezing?
Discharge (from nose, eyes, and/or genitals)?
Changes in urination or drinking habits?
Changes in energy or activity level?
Changes in mobility (limping, lameness, and/or soreness)?
Changes in behavior?
Changes in appetite?
Changes in weight/body condition?
Itchiness (scratching, licking, head shaking, etc)?
Any new lumps or bumps, or changes in existing ones?
Please describe your pet’s living environment. What percentage of the day does your pet spend outdoors and how is time spent outdoors (i.e, restricted to yard, free to roam; exposure to wildlife, hiking, camping; going to the beach, etc) Have you observed fleas and/or ticks on your pet?
*
What other animals (if any) does your pet live with currently? Please describe any other animals that your pet has frequent contact with (dog park, boarding, training classes, etc.)
*
Has your pet traveled within the past 12 months, or do you plan to travel with your pet within the next 12 months? If so, to where?
*
What medications (including supplements, flea/tick/heartworm preventives, vitamins, topical medications, CBD products) is your pet currently taking? Please include dose (i.e., 25mg or 1mL) and frequency (i.e., once daily, twice daily) of medications.
*
Please provide your pet’s vaccine history and name(s) of previous veterinary hospital(s) for us to contact to request records.
*
Has your pet had blood/urine testing performed within the past year? If so, please provide contact information for the facility where the lab work was performed.
*
What type/brand of food +/- treats does your pet eat and how much does your pet eat per day? Please include diet formulation (kibble vs canned) and whether food is home-cooked, grain-free, and/or raw.
*
For wellness (annual/senior) and consultation visits, please answer the following
Have you recently observed any of the following in your pet? (Please check what applies and provide details as needed)
Vomiting?
Diarrhea?
Coughing?
Sneezing?
Discharge (from nose, eyes, and/or genitals)?
Changes in urination or drinking habits?
Changes in energy or activity level?
Changes in mobility (limping, lameness, and/or soreness)?
Changes in behavior?
Changes in appetite?
Changes in weight/body condition?
Itchiness (scratching, licking, head shaking, etc)?
Any new lumps or bumps, or changes in existing ones?
Please describe your pet’s living environment. What percentage of the day does your pet spend outdoors and how is time spent outdoors (i.e, restricted to yard, free to roam; exposure to wildlife, hiking, camping; going to the beach, etc) Have you observed fleas and/or ticks on your pet?
*
What other animals (if any) does your pet live with currently? Please describe any other animals that your pet has frequent contact with (dog park, boarding, training classes, etc.)
*
Has your pet traveled within the past 12 months, or do you plan to travel with your pet within the next 12 months? If so, to where?
*
What medications (including supplements, flea/tick/heartworm preventives, vitamins, topical medications, CBD products) is your pet currently taking? Please include dose (i.e., 25mg or 1mL) and frequency (i.e., once daily, twice daily) of medications.
*
Please provide your pet’s vaccine history and name(s) of previous veterinary hospital(s) for us to contact to request records.
*
Has your pet had blood/urine testing performed within the past year? If so, please provide contact information for the facility where the lab work was performed.
*
What type/brand of food +/- treats does your pet eat and how much does your pet eat per day? Please include diet formulation (kibble vs canned) and whether food is home-cooked, grain-free, and/or raw.
*
Is your pet 7 years of age or older?
Yes
No
1. Locomotory/ambulatory assessment
No alterations or debilities noted
Modest slowness associated with change from youth to adult
Moderate slowness associated with geriatric aging
Moderate slowness associated with geriatric aging plus alteration or debility in gait
Moderate slowness associated with geriatric aging plus some loss of function (e.g., cannot climb stairs)
Severe slowness associated with extreme loss of function, particularly on slick surfaces (may need to be carried)
Severe slowness, extreme loss of function, and decreased willingness or interest in moving (spends most of time in bed)
Paralyzed or refuses to move
Comment Box
2. Appetite assessment
No alterations in appetite
Change in ability to physically handle food
Change in ability to retain food(vomits or regurgitates)
Change in ability to find food
Change in interest in food (may be olfactory)
Change in rate of eating
Change in completion of eating
Change in timing of eating
Change in preferred textures
Comment Box
3. Assessment of elimination function
Changes in frequency and "accidents"
Normal/No Change
No change in frequency, no “accidents”
Increased frequency, no “accidents”
Decreased frequency, no “accidents”
Increased frequency with “accidents”
Decreased frequency with “accidents”
No change in frequency, but “accidents”
Comment Box
Bladder control
No change in urination control or behavior
Leaks urine when asleep
Leaks urine when awake
Leaks urine when awake or asleep
Full-stream, uncontrolled urination when asleep
Full-stream, uncontrolled urination when awake
Full-stream, uncontrolled urination when awake or asleep
No leakage or uncontrolled urination, all urination controlled, but in inappropriate or undesirable location
Comment Box
Bowel control
No changes in bowel control
Defecates when asleep
Defecates without apparent awareness
Defecates when awake and aware of action, but in inappropriate or undesirable locations
Comment Box
4. Visual acuity: How well do you think the dog or cat sees?
No change in visual acuity detected by behavior, appears to see as well as ever
Some change in acuity not dependent on ambient light conditions.
Some change in acuity dependent on ambient light conditions
Extreme change in acuity not dependent on ambient light conditions
Extreme change in acuity dependent on ambient light conditions
Blind
Comment Box
5. Auditory acuity: How well do you think the dog or cat hears?
No apparent change in auditory acuity
Some hearing loss
Extreme hearing loss
Deaf
Comment Box
6. Play interactions: If the dog or cat plays with toys, which situation best describes that play?
No change in play with toys
Slightly decreased interest in toys
Slightly decreased ability to play with toys
Slightly decreased interest and ability to play with toys
Extreme decreased interest in toys
Extreme decreased ability to play with toys
Extreme decreased interest and ability to play with toys
Comment Box
7. Interactions with people: Which situation best describes that interaction?
No change in interaction with people
Recognizes people but slightly decreased frequency of interaction
Recognizes people but greatly decreased frequency of interaction
Withdrawal but recognizes people
Does not recognize people
Comment Box
8. Interactions with other pets: Which situation best describes that interaction?
No change in interaction with other pets
Recognizes other pets but slightly decreased frequency of interaction
Recognizes other pets but greatly decreased frequency of interaction
Withdrawal but recognizes other pets
Does not recognize other pets
No other pets or animal companions in house or social environment
Comment Box
9. Changes in sleep-wake cycle?
No changes in sleep patterns
Sleeps more during the day
Some change, awakens at night and sleeps more during the day
Much change, profoundly erratic nocturnal pattern and irregular daytime pattern
Sleeps virtually all day, awake occasionally at night
Sleeps almost around the clock
Comment Box
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