Illness / Injury Appointment History Form

Thank you for choosing Healing Paws Veterinary Care. The information you provide in this form allows us to personalize your pet’s care- focusing on what is best for both them and your family. We truly appreciate your time as these answers help us to keep your pet healthy and happy! If you have any questions, please give us a call. We look forward to seeing you and your pet!

We truly appreciate your time in giving us the following information as it allows us to be sure that your pet's testing and treatment recommendations are both thorough and personalized to fit your pet and family’s needs. Thank you!

Pet's Name(Required)

Name of owner to contact during the day of your pet’s visit:(Required)

First Last

It is important for the doctor to be able to reach you at any time during your pet’s stay. What is the number for the cell that you will have with you?(Required)

Name of secondary emergency medical contact during the day of your pet’s visit:(Required)

First Last

Secondary contact cell phone number:(Required)

Symptoms & Medical Concerns

Please select each symptom your pet is experiencing (even if only occasional). The more you can tell us the better!

Please select all of the following symptoms (even if they are slight) that your pet is experiencing.(Required)

How frequently are they rubbing/scratching/shaking their ears?(Required)

How long have you noticed them bothering their ears? Have they had ear problems before?(Required)

In the last week, have you applied anything (including cleansers) to the ears or has your pet been groomed/bathed?(Required)

How long have you noticed a change in your pet's eye or vision?(Required)

Which eye is affected (driver’s side, passenger side, or both)?(Required)

Does your pet appear to see normally?(Required)

Describe any discharge from the eye(Required)

Has your pet experienced any eye problems before?(Required)

In the last week, what, if anything, have you done for the eyes at home?(Required)

How long has your pet been sneezing and does anything come out when they sneeze?(Required)

If your pet has nasal discharge or something comes out when they sneeze, please describe the discharge.(Required)

How frequently is your pet sneezing when you are with them?(Required)

How long have you noticed a change in your pet's mouth or breath?(Required)

Describe what you have noticed going on with your pet's mouth/breath.(Required)

How has this changed the way your pet chews or what they are willing to eat?(Required)

How often does your pet cough in a 24 hour period?(Required)

Does the cough sound dry or wet as if they want to bring something up?(Required)

What (if anything) seems to trigger the cough?(Required)

If your pet is not coughing, but has changes in breathing, please describe the changes you are noticing.(Required)

Has your pet spent time in a daycare, boarding, or grooming facility in the last month?(Required)

Are there any scented oils, diffusers, or candles in your home?(Required)

Do you open windows in your home?(Required)

How much time does your pet spend outdoors?(Required)

Is the cough or change in breathing more frequent indoors, outdoors, or the same in both places?(Required)

Does anyone in your home use tobacco?(Required)

Does your pet bring up a hairball or only “hack”?(Required)

Does the hairball behavior occur daily, weekly, or monthly?(Required)

How often does your pet have a bowel movement? (Hairballs affect the gastrointestinal tract.)(Required)

Are the stools round firm balls, or soft logs?(Required)

In the last month, what, if anything, have you tried to alleviate the hairball behavior?(Required)

Has your pet experienced hairballs before or is this a new problem?(Required)

Does your pet lie flat on their side, curled up, or resting on their chest with their chin on the ground?(Required)

Does your pet sleep through the night?(Required)

Does your pet seem scared?(Required)

What percentage of the day is your pet panting?(Required)

What food (dry or canned) is your pet currently willing to eat?(Required)

What food (dry or canned) is your pet no longer willing to eat?(Required)

What does your pet do when you put out fresh food for them?(Required)

How much does your pet actually eat now compared to how much they ate when you last considered them normal?(Required)

What, if anything, have you tried to encourage them to eat or to deal with their hunger?(Required)

What does the vomit look like?(Required)

What (if anything) seems to trigger the vomiting?(Required)

Does your pet contract their abdomen to retch or is it a passive, easy vomit?(Required)

Does the vomiting occur daily, weekly, or monthly?(Required)

Are you aware of your pet eating any plants, new types of food, people food or treats within the last 2 weeks? If so tell us what and when this occurred.(Required)

Does your pet enjoy playing with small things or chew up toys/trash/etc?(Required)

When was your pet’s last bowel movement?(Required)

How many times did your pet vomit (events not piles) in the last 24 hours?(Required)

Is your pet urinating more, less, or the same amount of times per day?(Required)

Is your pet urinating larger, smaller, or the same amount of volume with each void?(Required)

Is your pet having “accidents”?(Required)

Is your pet licking their genital area?(Required)

What color urine are you noticing?(Required)

Does your pet seem to strain or have difficulty passing urine?(Required)

Is your pet drinking more, less, or the same amount of water?(Required)

Does your pet seem uncomfortable?(Required)

What things could be currently causing stress in your pet’s life (i.e. new furniture, visitors, changes in the home, other pets)?(Required)

Has anything recently changed about where your pet goes to the bathroom?(Required)

Please bring a fresh urine sample to the visit.

Is your pet defecating more, less, or the same amount of times per day?(Required)

Is your pet defecating larger, smaller, or the same amount of volume with each void?(Required)

Is your pet having “accidents”?(Required)

Describe the color of the stool(Required)

Is the stool closer to milk, pudding, soft serve ice cream, hard serve ice cream, bananas, raisins, or rocks in consistency?(Required)

Do you see mucus, red blood, or worms in the stool? If so which- does your pet seem to strain or have difficulty passing stool?(Required)

Does your pet seem uncomfortable?(Required)

When did your pet last receive a heartworm preventative and what kind was it?(Required)

Has your pet eaten anything different (including food, treats, people food, chews, plants, supplements) in the last 2 weeks?(Required)

Has anything recently changed about where your pet goes to the bathroom?(Required)

What, if anything, have you tried to alleviate this stool problem?(Required)

Has your pet experienced bowel or stool issues before?(Required)

Please bring a stool sample to the visit.

Please describe where these lumps/lesions/rashes are (we may also shave small spots on them for examination):(Required)

Is there any discharge or pain from any of the lumps or rashes?(Required)

How long has each lump or has the lesion/rash been present?(Required)

When you are with your pet, how often are they licking or scratching?(Required)

In the past month, what, if anything, have you tried to relieve the lumps or rash?(Required)

If there is a rash, have you noticed that anything lessens the itch or decreases the rash? (bath, etc)(Required)

Has your pet experienced any skin or lump issues like this before?(Required)

What type of flea and tick preventative does your pet use and when was the last dose given?(Required)

Do any other pets in the household have itching or skin lesions?(Required)

Do any people in the household have itching or skin lesions?(Required)

How much time does your pet spend outside?(Required)

Are there any new scented products, rugs or furniture in the home?(Required)

To your knowledge have any of the pets in your home or in a neighbor’s home ever had fleas? Are there wildlife or stray cats ever in your yard?(Required)

Are any of the other pets in your home not on flea/tick preventative?(Required)

Has your pet experienced this before?(Required)

How long has this been occurring?(Required)

Has your pet had soft stool at any time in the last month?(Required)

Has your pet had a change in diet in the last month?(Required)

Does your pet receive any people food?(Required)

Is your pet’s stool closer to milk, pudding, soft serve ice cream, hard serve ice cream, bananas, raisins, or rocks in consistency?(Required)

What brand of heartworm/intestinal parasite preventative does your pet receive and when was the last dose given?(Required)

What brand of flea/tick preventative does your pet receive and when was the last dose given?(Required)

Have you seen any blood at your pet’s anus or vagina?(Required)

Is your pet having any difficulty defecating?(Required)

Is your pet having any difficulty urinating?(Required)

What, if anything, have you tried to stop your pet from dragging or licking their bottom?(Required)

Has your pet experienced these symptoms of discomfort before?(Required)

How long has your pet been walking differently?(Required)

When is the change in walking most noticeable: after rest, after exercise or the same at all times?(Required)

Did your pet cry out at any time when this started?(Required)

Is your pet sitting differently?(Required)

Is your pet lying differently?(Required)

Is your pet resting well? (Sleeping with their eyes closed for hours at a time without getting up and moving).(Required)

What leg or legs do you notice being affected (please describe as driver’s side or passenger side)?(Required)

Have you noticed any swelling, redness or heat in the area of discomfort?(Required)

If your home has stairs, has your pet’s method of going up or down seemed to have changed at all?(Required)

Does your pet have difficulty walking on smooth surfaces?(Required)

What, if anything, have you tried to alleviate this discomfort?(Required)

Has your pet experienced this before?(Required)

What area seems painful to your pet?(Required)

How is your pet telling you they have pain?(Required)

How long have you noticed this pain?(Required)

What part of the day does the pain seem the worst?(Required)

Have you noticed any of the following additional symptoms?(Required)

Slowing down with age

Sleeping in different positions or different locations

Becoming friendlier or hiding more

Newly hungry all the time

Still Eating but eating less

Different Behaviors

None of the above

Please tell us what you are noticing(Required)

Has your pet had any x-rays, blood or urine testing done at a facility other than Healing Paws in the last 6 months?(Required)

Yes

Please tell us the name and number of the veterinary clinic so that we can obtain those results for our records and comparison.(Required)

Let's Work Together to Make Treatment Easier

We recommend whole pet care that may include medical, nutritional, surgical, supplemental, or integrative therapy. Help us help your pet by answering the following.

To help us make medicating your pet easier, please select all that applies:(Required)

What did you try to get them to take the pills? Tell us what this experience was like for both you and your pet?(Required)

What did you try to get them to take the liquid? If you recall, what flavor was the liquid? How stressful was this experience for both you and your pet?(Required)

Does your pet eat dry food/kibble?(Required)

Yes

What is the brand of food and how much do they eat?(Required)

Does your pet eat canned or moist food?(Required)

Yes

What is the brand of food and how much do they eat?(Required)

Does your pet eat treats, bones, chews or people food?(Required)

Yes

Does your pet currently take any prescribed medications (other than parasite preventatives)?(Required)

Yes

Even if you get the medication from us, it is very important to give as thorough detail as possible to avoid drug interactions. Please list the medications including how much and what times of day you give them.(Required)

Please tell us about both heartworm and flea/tick prevention you are using. What brand/brands? How often given? Approximately when was the last dose of each given?(Required)

Does your pet receive any over the counter medications, supplements, herbs, or vitamins?(Required)

Yes

Please list any of these products that your pet receives - including how much and what times of day you give them. It is very important to give us as thorough detail as possible to avoid drug interactions(Required)

Would you like any medication, supplements, dental care products, foods, or parasite preventatives refilled today?(Required)

Yes

Pease list all products and how many months supply you would like of each(Required)

Important Authorizations

Authorization to Perform Examination/Diagnostics/Treatment: I hereby authorize the Healing Paws Veterinary Care, Inc. staff and doctor to perform an examination. I understand that the condition my pet has may include them having pain or anxiety and also authorize the Healing Paws Veterinary Care, Inc. staff and doctor to provide short-term pain or anxiety relief to my pet during their stay. At the end of the examination, if the doctor feels that further diagnostic testing is necessary, the tests may be performed during my pet's visit. With the results of those tests, I understand that the doctor will personalize a treatment recommendation for my pet and then will review those recommendations with myself or my representative. I understand that receiving diagnostic testing and treatments allows my pet to feel more comfortable as soon as possible and allows the doctor to evaluate their results and treatments so that I can receive the most accurate treatment recommendation plan(Required)

I have read and understand this authorization and hereby accept and agree to the terms of the consent for examination pain or relaxing medication treatment as described above. I authorize the doctor and staff of Healing Paws Veterinary Care, Inc. permission to perform examination, tests, and treatments on my pet today and am responsible for the payment of these services. I understand that I will be contacted for further permission if the total of the examination, in-patient care, tests and treatments for my pets is over $500 today.

I do not give permission to perform anything other than examination with treatment for pain or relaxation until I receive the doctor’s recommendations and have signed an electronic treatment plan or paid the invoice via phone. I am responsible for the payment of the examination even if I decline any further tests or treatments. I understand that while the medical team will do their best to perform these procedures the same day if possible, the process of me receiving and returning this treatment plan may delay my pet’s testing, treatments, and discharge time or may require a second appointment to perform these procedures.

CPR/DNR Consent

In the unlikely event that the above-named pet should experience cardiac or respiratory arrest while being at Healing Paws Veterinary Care today, we need to know, in advance, what your wishes are for your pet. If your pet does experience cardiac or respiratory arrest, we will absolutely inform you. However, your pet's safety and well-being come first, so we need you to direct us here as to your wishes for their care.

Cardiopulmonary Resuscitation (CPR):

All resuscitative efforts are to be attempted to restore normal heart function and to breathe as deemed necessary by the doctor until I can be reached. Should my pet require cardiopulmonary resuscitation (CPR), I request that the doctor(s) pursue medical care. I understand that this is a cost in ADDITION to any other services provided, and I agree to pay this fee. The cost of full CPR is typically at least an additional $300 or more and in no way guarantees that my pet will survive their cardiac or respiratory event. Patients who require CPR typically need at least 24 to 48 hours of intensive care and monitoring at a specialty facility following resuscitation. It will be necessary for me to transport my pet to the specialty facility, and I will be responsible for the charges for my pet's care at that facility.

Do Not Attempt Resuscitation (DNR):

No cardiopulmonary resuscitation (CPR) efforts will be performed in an effort to save my pet if they have cardiac or respiratory arrest; only the administration of medication to help ease my pet's passing may be used.

Please select the option you'd like the doctors to proceed with.(Required)

I agree to CPR being performed in case of arrest. However, if CPR has been performed for 30 minutes, and my pet is unable to support cardiac or respiratory function on their own, I authorize the doctor on duty to make the decision to discontinue CPR which may result in my pet's death.

I elect a “Do Not Resuscitate” status in case of arrest. If my pet is actively suffering during its cardiac and/or respiratory arrest, the doctor may give a euthanasia solution to ease its passing.

I elect a “Do Not Resuscitate” status in case of arrest. The doctor does not have permission to give my pet euthanasia solution but should remove airway support if they are experiencing cardiac or respiratory arrest.

Information About Veterinary Medical Care

I realize that no guarantee or warranty can ethically or professionally be made regarding outcomes of treatment of medical illnesses or effectiveness of preventative care products and procedures. I have been informed that there are certain risks and complications associated with disease, sedation, anesthesia, and/or any operation/procedure and that while the team at Healing Paws Veterinary Care, Inc has my pet's best interest in mind at all times, sometimes complications occur. I further understand that during the course of the examination, diagnostics, procedures, or treatments, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before treatment or diagnostics are initiated. I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatment. I have been encouraged and given the opportunity to discuss any questions I may have regarding my pet's medical care. I accept that my financial obligations remain regardless of the outcome of treatment.

I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute consent for examination, diagnostic testing, procedures, and treatment of said animal. I have read and understand this authorization and hereby accept and agree to the terms of the consent for examination and treatment. I understand that I am financially responsible for any services, products, or treatments provided to my pet and that I can request a treatment plan and cost estimate for my pet at the time of my visit.(Required)

I have read and understand

My signature below certifies that I am over eighteen years of age.(Required)

Date(Required)

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