Patient admitting form – Senior Canine Time* Hours: Minutes AMPM Date* MM slash DD slash YYYY Client Name* First Last Pet Name*Age*Breed*1. What concerns you about your pet today (please be specific)?*2. How long has this problem been going on?*3. Is your pet:* Indoor Outdoor Both4. Please answer Yes or No to all of the following:Is there any: Vomiting* Yes NoIf yes, for how long?*Is there any: Diarrhea* Yes NoIf yes, for how long?*Is there any: Coughing* Yes NoIf yes, for how long?*Is there any: Sneezing* Yes NoIf yes, for how long?*6. What brand of dog food are you currently feeding your dog?*7. If your dog is currently taking medications, list the medication and dosing instructions below: (please be specific so we can verify this with what is in your patients medical record)*MedicationDosage Add Remove8. Was the medication given today?* Yes NoIf yes, what time?*9. What brand of flea and tick prevention is your pet on? (please be specific so we can verify this with what is in your patients medical record)*10. What brand of heartworm prevention is your pet on? (please be specific so we can verify this with what is in your patients medical record)*11. Is your pet microchipped?* Yes No12. Is your pet current on its Rabies vaccine?* Yes No13.Has your pet had a fecal analysis in the last 6 months?* Yes No14. Are there other pets at home?* Yes NoHow many?*Cat(s)Dog(s)Other(s)15.Please answer yes or no to the following questions:15a. Is your pet spayed/neutered?* Yes No15b. Weight fluctuation?* Yes No15c. Changes to eating habits?* Yes No15d. Apparent trouble chewing?* Yes No15e. Changes to sleeping habits?* Yes No15f. Does your pet wake in the middle of the night?* Yes No15g. Does your pet seem restless/hard to get comfortable?* Yes No15h. Any apparent lameness in any limbs?* Yes No15i. Any apparent pain when getting up?* Yes No15j. Is your dog still willing to go for walks?* Yes No15k. Does your pet vocalize when rising/walking?* Yes No15l. Does your dog seem bored?* Yes No15m.Does your dog have a comfortable bed/toys?* Yes No15n. How many hours per day/night is your dog alone?*15o. Does your dog seem disoriented/wander?* Yes No15p. Is your dog increasingly anxious, fearful, or irritable?* Yes No15q. Any unusual vocalization?* Yes No15r. Has your dog's social habits changed?* Yes No15s. HAs your dog ever had a seizure?* Yes NoIs yes, how many/how often?16. Do you authorize: Blood work* Yes No16. Do you authorize: X-Rays* Yes No17. Do you have insurance for your pet?* Yes No17 a. If yes, what insurance provider do you have? (If none, put n/a)*18. Do you need any written prescriptions or any medication filled at the time of the appointment (this includes prescription food or flea/tick prevention)? PLEASE SPECIFY WHETHER YOU NEED A WRITTEN PRESCRIPTION OR IF YOU NEED IT FILLED IN HOUSE.19. I authorize Martinez Animal Hospital to charge up to?*(Expenditures over this amount requires authorization)20. In order to treat your pet in a timely manner, it is extremely important that we are able to reach you by phone throughout the day. Please leave a number that will be answered and checked throughout the day.*PrimaryAlternate PLEASE NOTE!! If your pet has fleas, we will apply flea treatment at your expense.Signature*Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
