Feline Wellness Form Carlson

Feline Wellness Questionnaire
We thank you for helping us give you the best service possible by completing this
form within 24 hours of receiving.

PLEASE BE ADVISED: WE ARE CURRENTLY ONLY OFFERING CURBSIDE SERVICE.

WE REQUIRE ALL PATIENTS TO ARRIVE WITH A LEASH/COLLAR OR CARRIER.
When you arrive for your appointment, please call and we will give you further instructions. Due to the high level of calls, you may experience longer hold times. We are doing our best to get to you as quickly as possible and appreciate your patience and understanding during this time.
COVID Screening Questions
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, fever, cough, chills, body aches, shortness of breath, loss of smell or taste? *

Yes No
Have you or anyone in your household been tested positive for COVID-19? *

Yes No
Have you or anyone in your household traveled outside the state or US in the past 21 days? *

Yes No
If so, where did you travel to?
IF YOU ANSWERED YES TO ANY OF THESE QUESTIONS, PLEASE CALL OUR HOSPITAL TO DISCUSS OUR PROTOCOL.
Important Information
Your First and Last Name (On Account) *
Phone Number To Contact You During Appointment *
Please enter a valid phone number.
Please list any concerns you would like us to address during your visit *
Please list any additional services you would like to request during your appointment, in the box below (i.e. nail trims, anal sac expression, ear cleaning etc.): *
While we always try our best to fit in any requested services but please be aware, performing additional services will ultimately depend on appointment times and staff availability. If not applicable, please write none in the box
Patient Questionnaire
Your Pet's Name
Appetite and Diet
Is your pet's appetite: *

Normal Decreased Increased
Is your pet's water intake: *

Normal Decreased Increased
What BRAND and TYPE of food does your pet eat? (canned/dry) *
Amount fed per meal *
Frequency of meals *
Gastrointestinal Health
If your pet is experiencing any vomiting, please describe: *
(date of onset symptoms, frequency, color, texture etc) If not applicable, please write none in the box
If your pet is experiencing any diarrhea, please describe: *
(date of onset symptoms, frequency, color, texture etc) If not applicable, please write none in the box
Respiratory Health
If your pet is experiencing coughing, please describe: *
(date of onset symptoms, frequency, color, texture etc) If not applicable, please write none in the box
If your pet is experiencing any sneezing, please describe: *
(date of onset symptoms, frequency, color, texture etc) If not applicable, please write none in the box
Sensory Health
If your pet is experiencing any eye issues, please describe: *
(date of onset, symptoms, which eye, discharge, color etc) If not applicable, please write none in the box
If your pet is experiencing any ear issues, please describe: *
(date of onset, symptoms, which ear, discharge, color etc) If not applicable, please write none in the box
If your pet is experiencing any skin issues, please describe: *
(date of onset, location, symptoms) If not applicable, please write none in the box
If your pet is experiencing any mobility issues, please describe: *
(date of onset, symptoms observed etc) If not applicable, please write none in the box
Is your pet's activity level: *

Normal Decreased Increased
If any changes please describe
Lifestyle and Preventatives
What brand of heartworm preventative does your pet receive? *
Does your pet receive this:

Year Round Seasonally N/A
What brand of flea/tick preventative does your pet receive? *
Does your pet receive this:

Year Round Seasonally N/A
Does your pet spend most of it's time: *

Indoors Outdoors Both
Medications and Refills
Please list any medications that your pet is currently on (include name, strength, dose, and frequency): *
If not applicable, please write none in the box
Please list any refills needed for medications, preventatives or prescription food here *
If not applicable, please write none in the box
CANCELATION POLICY

While we do understand emergencies and other scheduling conflicts can happen and are sometimes unavoidable, we request a 24-hour notice to change or cancel an appointment. After two missed or canceled appointments without the appropriate 24-hour notice, Carlson Animal Hospital will apply a $50.00 cancellation fee.

Thank you for completing this questionnaire. If you have any questions please call us 708.383.3606
Should be Empty:

Feline Wellness Questionnaire

COVID Screening Questions

Important Information

Patient Questionnaire