Curbside Check-In Form Medical History/Risk AssessmentPet's NameOwner's Name First Last Date Date Format: MM slash DD slash YYYY Reason for visitCurrent medications/supplementsDo you ever give your pet over-the-counter medications (i.e. Aspirin, Tylenol, Advil, etc.)?YesNoHas your pet been diagnosed with a heart condition or have a history of seizures?YesNoPlease list any other pet(s) in your household:Dog - Name(s)Breed(s)Cats - Name(s)OtherMouth No Problems Bad Breath Difficulty Eating Other OtherEyes No Problems Vision Loss Drainage Other OtherEars No Problems Scratching Odor Other OtherSkin No Problems Scratching Hairloss Other OtherAppetiteNormalDecreasedIncreasedWater intakeNormalDecreasedIncreasedUrinationNormalDecreasedIncreasedActivityNormalDecreasedIncreasedMobilityNormalDecreasedInability to Stand Jump Up Run CoughingNoYes(If Yes) FrequencySneezingNoYes(If Yes) FrequencyVomitingNoYes(If Yes) FrequencyDiarrheaNoYes(If Yes) FrequencyBehaviorNoYes(If Yes) FrequencyVaccination statusCurrentNeededNeededWhat do you feed your pet?How often?OnceTwiceDoes your pet stayInsideOutsideBothDoes your pet Got to Park/Trail Travel with you out of the area Board/Get groomed What parasite control do you use?
