780-250-1700
2531 – 17th Street NW Edmonton, AB
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Ultrasound Consent Form
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Feline Patient Admission Form
Recheck Exam Admission Form
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Diarrhea Questionnaire
Vomiting Questionnaire
Itching Questionnaire
Canine Cognitive Dysfunction Syndrome Assessment
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Itching Questionnaire
Date
*
Date Format: MM slash DD slash YYYY
Client Name
*
First
Last
Patient Name
*
First
Last
Age
*
Breed
*
Sex
*
Male
Neutered Male
Female
Spayed Female
PHYSICAL EVALUATION
Please check any that describe your pet:
*
Hair loss
Foul odour
Inflammation or redness
Itching/scratching
Otitis (ear infections)
Licking/chewing
Skin lesions (sores)
Changes in skin (reddish/brown stains, discolorations and/or areas that are thick and leathery)
Has your pet ever had any ear problems?
*
Yes
No
Does your pet have any chronic gastrointestinal signs like diarrhea or vomiting?
*
Yes
No
SEVERITY EVALUATION
Severity of condition overall
*
0
1
2
3
4
5
6
7
8
9
10
On a scale of 1-10 (0 being no symptoms, 10 being severe), rank the severity of your dog's symptoms:
Severity of skin lesions
*
0
1
2
3
4
5
6
7
8
9
10
On a scale of 1-10 (0 being no symptoms, 10 being severe), rank the severity of your dog's symptoms:
Severity of scratching/licking/chewing
*
0
1
2
3
4
5
6
7
8
9
10
On a scale of 1-10 (0 being no symptoms, 10 being severe), rank the severity of your dog's symptoms:
ONSET AND SEASONALITY EVALUATION
Is this the first time your dog has experienced these symptoms?
*
Yes
No
If no, at what age did the symptoms first occur?
If no, has it occurred around the same time of year each time?
If no, approximate time of year symptoms occur
How long have the current symptoms been going on for?
*
Did the itch start gradually and over time became worse?
*
Yes
No
Did the itch come on suddenly without warning?
*
Yes
No
Was there a "rash" first or itching first? Or simultaneous?
*
Rash first
Itch first
Simultaneous
PARASITE CONTROL
Is your pet on a flea/heartworm preventative?
*
If so, what product?
What months do you administer the preventative?
*
When was the last time you administered the parasite control?
*
LIFESTYLE EVALUATION
Where does your pet live? (Indoors, Outdoors, Both?)
*
If outdoors, please describe the environment.
Are there other pets in the household?
*
If yes. do these pets have the same symptoms? If these pets are cats, do they go outside?
Do your board your dog, take him or her to obedience school, training or groomers?
*
If yes, when was the last time you took your dog?
Have you taken your dog on a trip to another location?
*
If yes, please indicate when and location
Have you recently moved?
*
Yes
No
Have you been to a new dog park with your dog or walking trail?
*
Yes
No
Have you used any new shampoo or topical skin treatments recently?
*
Yes
No
Are any humans in your household exhibiting signs?
*
Yes
No
DIETARY EVALUATION
What pet food are you feeding?
*
Do you feed the same food all the time or provide a variety?
*
Always the same
Variety
Have you recently changed the food?
*
Yes
No
Do you give your pet packaged treats?
*
Yes
No
Do you feed your pet human food?
*
Yes
No
RELATIONSHIP/BEHAVIOURAL EVALUATION
Sleeps through the night:
*
Always
Usually
Occasionally
Never
Activity Level:
*
Inactive
Much less inactive
Somewhat less active
No change
Social Behaviour:
*
Unsocial
A lot less social
Somewhat less social
No change
Relationship Changes:
*
Fewer walks
No longer sleeps in bed/same room
Interacts less with family
PRIOR TREATMENTS
Has your dog been treated for itching before?
*
Yes
No
Indicate previous treatments administered to your dog:
*
Steroids
Shampoos
Sprays
Ointments
Antibiotics
Hypoallergenic food
Essential fatty acids
Antihistamines
Immunotherapy
Check all that apply
Home
Contact
New Clients
What to Expect
New Client Registration Form
Prescription/Food Refill Request
About Us
Team and Pet Bios
Location & Hours
Make an Appointment
Fear Free Clinic
Services
Medical Services
Surgical Services
Anesthesia and Patient Monitoring
Nutritional Counseling
Additional Services
Pet Health
Pet Health Library
Pet Health Checker
How-To Videos
News
Forms
Consent Forms
General Anesthesia Consent
Euthanasia Consent Form
Echocardiogram – Drop Off Consent Form
Drop Off Consent Form – with sedation
Drop Off Consent Form
Overnight Hospitalization – Drop Off Consent Form
Blood Glucose Curve – Drop Off Consent Form
Dental Surgery Consent Form
Spay/Neuter Surgery Consent Form
Telemedicine Consent Form
Ultrasound Consent Form
Admission Forms
Canine Patient Admission Form
Feline Patient Admission Form
Recheck Exam Admission Form
Questionnaires
Diarrhea Questionnaire
Vomiting Questionnaire
Itching Questionnaire
Canine Cognitive Dysfunction Syndrome Assessment
Shop Online
Contact Us
Name
*
First
Last
Email
*
Phone
*
Pet Name
*
Preferred Date
*
MM
DD
YYYY
Preferred Time
*
:
HH
MM
AM
PM
Reason for appointment
*