VBS Canine Recheck Form
The information you provide below will be used during your consultation to develop a diagnosis and plan of treatment. Please fill it out as completely as you can. All information will be held in strict confidence and will not be released to any third party without your written consent.
Please submit this form
at least 2 business days
prior to your dog’s appointment date
Today's Date
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Your Contact Information
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First Name
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Home Phone Number
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Your Family Veterinarian's Contact Information
Family Veterinarian
*
Hospital Name
*
Hospital Address
*
Veterinarian's Phone Number
*
Do you authorize us to send a summary of the consultation to your family veterinarian?
*
Yes
No
I would like to discuss this further at the consultation.
Your Dog's Information
Dog's Name:
*
Dog's Breed
Dog's Birthdate
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Month
-
Day
Year
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Dog's Current Weight
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Spayed or Castrated?
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Yes
No
Age at which Spayed or Castrated?
*
Sex:
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Male
Female
Color:
*
% of time indoors:
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% of time outdoors:
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Of total time spent indoors how long is the dog in a crate?
*
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Behavior History
How do you feel your dog has progressed since the last appointment?
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Have there been changes in frequency or exhibition of the behavior problem?
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Are there any new behavior problems you would like to address?
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Medical History
Please describe new or current medical problems of your dog:
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Is your dog currently on any medication or special diet?
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Yes
No
Please list all current medications WITH DOSAGES including heartworm, flea and tick prevention
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Please list all vaccines given within the last year (include dates given):
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Please describe all the people living in the household now, starting with yourself:
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Your Dog's Daily Routine
Feeding
Type of food consumed:
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Canned
Moist
Dry
Human Food
Brand of Food:
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Supplements / Snacks:
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Daytime
During the day where does your dog spend time?
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Hours Indoors:
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If Indoors, is the dog:
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in a crate
free roaming
Hours Outdoors:
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if outdoors, is the dog:
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on leash
in a pen
free roaming
Exercise
Types of exercise:
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How many hours per day?
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How many hours per week?
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With which family members?
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What is your dog's activity level in general?
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Low
Average
High
Excessive
List the types of toys your dog has and indicate which toys are preferred or are your dog’s favorites:
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Other Animals
List all animals in the household in the order they were acquired, including pets who have died within the last year:
Do you currently have or have you had other animals in the home within the last year?
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Yes
No
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Do you have pet insurance for your dog?
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Yes
No
If yes, what insurance company?
Please feel free to add any other information you feel is pertinent:
*
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