| Today's
Date: |
Date
of first consultation: |
| Was
the original consultation a Clinic Visit
(if so please give us your pet's case number),
a PetFax or a Vetfax? |
| Name
& Address of owner: |
Daytime
phone:
Evening phone: |
Fax
number: |
| Name
of animal: |
| Species: |
Breed: |
| Sex:
Male/Female? |
Spayed
or castrated? |
| Age: |
Weight: |
Date
of last physical examination:
(Please include copies of any relevant medical
records and/or blood work.) |
| Any
medical problems currently or since last
consultation? |
| Any
current medication? |
| Briefly
describe the original problem(s): |
| What
was the diagnosis and treatment plan? |
| Were
you able to follow the treatment recommendations
and what were the results? |
| Please
describe the problem currently. Has the
frequency of the incidents increased or
decreased (how often does it occur)? Has
the intensity of the problem increased or
decreased (for example, when performing
the behavior, is he/she more easily interrupted
than before? Has he/she progressed from
growling to biting?) Has there been any
change in the pattern of behavior? |
| Please
give a detailed description of the last
time this problem occurred: |
| Are
there any new problems? If so, please give
a description of the problem(s): |
| Age
of onset: |
| Duration
of each incident: |
| Frequency
of occurrence: |
| Have
there been any changes in the pattern, frequency,
intensity and/or length of incidents from
the time of onset to the present? |
| Are
there any specific conditions which trigger
the behavior? |
| Can
your pet be interrupted when engaged in
the behavior? |
| How
long is the interval between the behavior
stopping and the beginning of the next occurrence? |
| Describe
any methods used to stop the behavior and
the pet's response to these methods: |
| Please
give a detailed description of the last
time this problem occurred: |
| Have
you obtained any new information about your
pet's past (for example, information about
siblings or parents)? |
| List
people in the house (by name) living with
your pet, include children's ages. Also
describe interactions between the pet and
people. Please note any changes since the
last consultation: |
| List
other animals in the household (by name),
their species, breed, age, sex, and whether
or not they are neutered. Also describe
interaction between the animals. Please
note any changes since the last consultation: |
| Have
there been any changes to your pet's environment
(for example have you moved, installed a
new fence, or changed the location of food
or litterboxes). |
| Please
describe a typical 24 hour period in your
pet's life, especially noting any changes
since the last consultation: |
| DIET |
| Type
of food including brand name, formula (e.g.
senior), and form (dry, canned, or semimoist): |
| How
much do you feed and how often: |
| Any
additional food/treats/table scraps: |
| EXERCISE |
| Describe
the exercise your pet receives including
how often it occurs: |
| OBEDIENCE |
| What
commands does your pet know and how well
does he/she respond: |