Animal Hospital of Lake Villa • Exam Form

Name *

First

Last

Email

Phone *

For quality and training purposes all phone calls are recorded.

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Vehicle make, model, and color? *

Curbside Optional

Would you like to remain curbside for today's appointment? *

Yes
No

Our lobby will remain closed. Please call or text when you arrive. We will escort you into an open room!

Patient name *

If you're bringing multiple pets, this form will need to be filled out twice.

Does your pet have medical insurance? *

Yes
No

If yes, who is the provider?

Trupanion, Embrace, Figo, Nationwide, Etc.

Patient species *

Canine
Feline

Cat carrier release *

I understand that Animal Hospital of Lake Villa requires that I bring my cat in a properly working carrier. I have been informed that Animal Hospital of Lake Villa is happy to rent out a carrier should we need it. I release Animal Hospital of Lake Villa and their team members from responsibility should I decide otherwise and my cat run away from my failure to bring him/her/them in an appropriate pet carrier.

Dog handling release *

I understand that Animal Hospital of Lake Villa requires that I bring my dog on a leash using a properly fitting collar or harness. I have been informed that Animal Hospital of Lake Villa has a double leash policy and as such, they will place an additional slip lead on my dog. I have been informed that this is done for the safety of my pet as Animal Hospital of Lake Villa is off of two busy roads. I have been informed that it is recommended that I step out of my vehicle, and hand the leashes over to the technician rather than opening the doors to let my dog out. I release Animal Hospital of Lake Villa and it's team members from responsibility should I not follow these guidelines described to me and let my dog loose.

Are there any peanut allergies in your household? *

Yes
No

We may use peanut butter to help win your pet over as a part of our Fear Free approach.

What is your pet here for today? *

If other, what are we checking/re-checking today? *

How long has this issue been going on? *

Seizure Questions

Is this your pet's first seizure? *

Yes
No

If no, when did the first one occur? *

Was this episode more or less intense than the last episode? *

Yes
No
About the same

Is your pet currently on anti-seizure medication? *

Yes
No

How frequent are the seizures? *

How long did the seizure last? *

Did your pet remain conscious during the seizure? *

Yes
No

Was the seizure related to eating? *

Yes
No

Is there a specific event that triggered the seizure? *

Was there an exposure to any toxins? *

Yes
No
Unsure

If yes, what was your pet exposed to? *

Puppy Questions

Kitten Questions

Is This Your Puppy's First Visit to Our Clinic? *

Yes
No

Is This Your Kitten's First Visit to Our Clinic? *

Yes
No

Where Did You Get Your Puppy From? *

Where Did You Get Your Kitten From? *

If Other, Where? *

How Long Have You Had Your New Puppy? *

How Long Have You Had Your New Kitten? *

If Other, How Long? *

Has Your Puppy Received Any Vaccines? *

Yes
No
Unknown

Has Your Kitten Received Any Vaccines? *

Yes
No
Unknown

If Yes, Who Gave These Vaccines? *

Has Your Puppy Received Any Deworming Treatments? *

Yes
No
Unknown

Has Your Kitten Received Any Deworming Treatments? *

Yes
No
Unknown

If Yes, Who Gave These Deworming Treatments? *

Have You Noticed Any Issues or Problems With Your Puppy? *

Yes
No

Have You Noticed Any Issues or Problems With Your Kitten? *

Yes
No

If Yes, Please Explain *

How Much Time Will Your Puppy Spend Outside? *

How Much Time Will Your Kitten Spend Outside? *

Have You Noticed Any Fleas Or Ticks On Your Puppy? *

Yes
No

Have You Noticed Any Fleas Or Ticks On Your Kitten? *

Yes
No

Recheck Questions

What Are We Rechecking Today? *

Please give as much description as possible.

Do You Think the Issue Has Gotten Better, Worse, Or Stayed the Same? *

Better
Worse
Stayed the same

Limping Questions

Which Leg or Paw is Affected? *

Front left
Front right
Back left
Back right

Check all that apply.

Approximately When Did the Limping Start? *

Was There an Accident or Any Known Trauma to the Leg or Paw? *

Yes
No

If Yes, Please Explain *

Can Your Pet Run? *

Yes
No

Can Your Pet Jump? *

Yes
No

Can Your Pet Play? *

Yes
No

Difficulties Going Up Or Down Stairs? *

Yes
No

When Does the Limping Get Worse? *

After Resting Or Laying Down
After exercise
Constantly limping
Other

Check all that apply.

If Other, Please Explain. *

Does the Limping Improve After Exercise? *

Yes
No

Has This Happened Before? *

Yes
No

If Yes, Please Explain *

Sneezing Questions

How Long Has This Been Going On? *

How Often Does Your Pet Sneeze? *

Is There Any Discharge Coming Out? *

Yes
No

If Yes, What Color is the Discharge? *

Does Your Pet Sound Congested? *

Yes
No

Have You Noticed Any Wheezing Sounds? *

Yes
No

Coughing Questions

How Long Has This Been Going On? *

What Does the Coughing Sound Like? *

Dry
Wet
Other

If Other, Please Describe. *

Is Anything Being Coughed Up (Mucus, Etc.)? *

Yes
No

If Yes, What Does it Look Like? *

Does Your Pet Sound Congested? *

Yes
No

When Does the Coughing Occur? *

If Other, Please Explain *

Is the Coughing Worse With Excitement or Exercise? *

Yes
No

Does the Coughing Wake Your Pet Up? *

Yes
No

Vomiting Questions

How Long Has This Been Going On? *

How Many Times Has He/She Vomited? *

How Frequent is the Vomiting? *

Once daily
Several times a day
Hourly
Other

If Other, Please Explain *

Is He/She Vomiting After Eating or Drinking? *

Yes
No
Not Sure

How Long After Eating or Drinking? *

What Does the Vomit Consist of? *

If Other, Please Explain. *

What Color is the Vomit? *

If Other, Please Explain. *

Was Any Blood Observed in the Vomit? *

Yes
No
Not Sure

How Much Blood Was Observed (Teaspoon, Tablespoon etc.)? *

What Was the Color of the Blood (Dark or Light)? *

Is the Blood Mixed Into the Vomit, Or Does it Present at the End of Vomiting? *

Is Your Pet Still Eating? *

Yes
No

Is Your Pet Able to Keep Food Down? *

Yes
No

Has Your Pet Ingested Any Unusual Items? *

Yes
No
Not Sure

If Yes, What Was Ingested? *

Is Your Pet Still Drinking Water? *

Yes
No
Not Sure

If Yes, How Much Water? *

Is Your Pet Able to Keep the Water Down? *

Yes
No

Has Any Foreign Substances Come Up with the Vomit? *

Yes
No
Not sure

If Yes, What Came Up with the Vomit? *

Diarrhea Questions

Please bring in a fresh fecal sample. This sample must be no more than 24 hours old, and cannot be frozen.

Is There an Urgency to Defecate? *

Yes
No

How Long Has the Diarrhea Been Occurring? *

How Many Times Has Your Pet Had Diarrhea During That Time? *

How Frequently Does Your Pet Have to Defecate? *

1 to 3 times per day
4 to 6 times per day
Every 1 to 2 hours
Other

If Other, Please Explain. *

Is This More or Less Than Usual? *

More
Less

What Would You Grade the Fecal Score as? *

1 - Dry, hard nuggets
2 - Comes out in segments, firm but not hard
3 - Comes out in segments not soft but still moist
4 - Comes out in segments and holds shape but very moist and soft
5- Soft server, can see a tube like shape but gels together
6 - Cow pie, very soft, no shape, does not spread out in a thin layer
7 - Liquid

Is There Any Straining Observed While Defecating? *

Yes
No

Is Your Pet Having Accidents in the House? *

Yes
No

Have You Observed Blood in the Stool? *

Yes
No

Is the Blood Red in Color? *

Yes
No

Is the Blood Seen at the End of Defecation, Streaked on the Surface of the Stool, or Mixed Throughout the Stool? *

At the end of defecation
Streaked along the surface of the stool
Mixed throughout the stool

Have You Observed Any Mucus in the Stool? *

Yes, at the end of defecation
Yes, streaked on the surface
Yes, mixed throughout the stool
No mucus was observed

What Was the Color of the Stool Itself? *

If Other, Please Explain. *

When Was the Last Bowel Movement? *

Is There Any Gas, Flatulence, or Gut Gurgling? *

Gas
Flatulence
Gut gurgling
None of the above

Check all that apply.

Does Your Pet Seem Painful? *

Yes
No

If Yes, In Which Area? *

Eye Questions

Which Eye is Affected? *

Left
Right
Both

Is Your Pet Squinting? *

Yes
No

Is There Any Discharge From the Eye(s)? *

Yes
No

What Color is the Discharge? *

How Long Has This Issue Been Going On? *

Is There Any Past Issues with the Eye(s)? *

Yes
No

If Yes, Please Explain *

Is There Any Recent Exposure to Chemicals? *

Yes
No
Not sure

If Yes, Please Explain. *

Ear Questions

Which Ear is Affected? *

Left
Right
Both

Is There Odor Coming From the Ear(s)? *

Yes
No

Is There Discharge Coming From the Ear(s)? *

Yes
No

What Does the Discharge Look Like? *

When Did You First Notice The Problem? *

Is There Any Past History of Ear Problems? *

Yes
No

If Yes, Were There Any Medications That Seemed to Help? Anything That Didn't Help? *

Have You Noticed Any Head Tilting? *

Yes
No

Has Your Pet Been In Water Recently? *

Yes
No

Do the Ear(s) Seem Painful? *

Yes
No

Have You Used Any Over-The-Counter Ear Cleaning Products In the Ear(s) Recently? *

Yes
No

If Yes, Which One(s)? *

Dermatology (Skin) Questions

Does Your Pet Itch/Lick/Chew/Bite Itself? *

Yes
No

Where Does Your Pet Itch Itself? *

Check all that apply.

When Did You First Notice the Problem? *

How Frequently is Your Pet Itching? *

How Bad is the Itching? *

Mild
Moderate
Severe

Does Your Pet Have Hair Loss? *

Yes
No

Is Your Pet Outdoor a lot? *

Yes
No

Is This Problem Seasonal? *

Yes
No
Not sure

Has This Happened Before? *

Yes
No

Urinary Questions

Please bring in a fresh urine sample that is no more than 30 minutes old. If you cannot grab a urine sample, please do not let your pet urinate for 2 hours before the appointment. When you arrive we may attempt to collect the sample for you.

What Urinary Problems Is Your Pet Experiencing? *

Check all that apply

If Other, Please Explain *

Has This Happened Before? *

Yes
No

Approximately When Did the Issue Begin? *

Is Your Pet Leaving Wet Urine Spots When Sleeping? *

Yes
No

Have You Noticed Excessive Licking of the Genital Area? *

Yes
No

How Much Volume Is Your Pet Urinating? *

1-2 teaspoons
1/2 cup
Unsure, haven't noticed

Did You Bring In a Urine Sample Today? *

Yes
No

When Was This Sample Taken? *

How Is Your Pet's Water Intake? *

Normal
Increased
Decreased
I haven't noticed

General Wellness Questions

What Brand Food Does Your Pet Currently Eat? *

What is the Main Source of Protein in Your Pet's Diet? *

If Other, Please Explain *

How Many Times a Day Do You Feed Your Pet? *

How Much Do You Feed Your Pet? *

Ex: 1/2 cup per feeding.

What Treats Do You Feed Your Pet? *

Is your pet on any medications currently? *

Yes
No

If Yes, Please List By Name & Dosage *

Are you looking to refill this medication today? *

Yes
No

Any other pets in the house? *

Yes
No

If Yes, Are They Currently Vaccinated? *

Yes
No
Not sure

If, Yes, Are They Current On Flea, Tick and Heartworm Preventions? *

Yes
No
Not sure

Does Your Pet Visit Any of the Following Places? *

Check all that apply.

Does Your Pet Visit Any of the Following Places? *

Boarding facility
Groomer
Pet stores
None of the above

Check all that apply.

Does Your Pet Have Any of the Following Symptoms? *

Check all that apply.

Is Your Pet Current On Parasite Prevention (Heartworm, Flea & Tick)? *

Yes
No
Not sure

If yes, what preventions are currently given? *

EX: Heartgard, Sentinel, Simparica, etc.

Do You Need Any Preventatives for Your Pet? *

Yes
No

Which Preventatives Do You Need for Your Dog? *

Heartgard Plus (heartworm)
Nexgard (flea & tick)
Simparica Trio (heartworm, flea & tick)
Other

Check all that apply.

Which Preventatives Do You Need for Your Cat? *

Revolution Plus
Revolution
Other

Check all that apply.

If Other, Which Preventatives Do You Need? *

Are You Interested In Finding Out If Hidden Stresses In Your Home Can Be Effecting Your Pet's Happiness Level? *

Yes
No

Certain health issues can be attributed to stress, causing the body to react in ways we see as allergies, inappropriate urination, etc. An added charge of $49 applies.

Do You Have Past History For Your Pet You Can Upload?

Click or drag files to this area to upload. You can upload up to 3 files.

Any Additional Notes for the Doctor?

If We Take Pictures Today, May We Use Them For Our Own Social Media or Marketing? *

Yes
No

Important Notice For Clients Who Leave During Visit. *

Please do not leave during your pet's appointment as we need to communicate with you about your pet's care. Due to limited space and personnel, any clients that leave during their pet's appointment will be charged an additional $63.70 boarding fee.

Payment Options *

The undersigned also understands that all services are to be paid in total when the pet(s) is/are discharged unless prior arrangements are made. The owner or agent promises to pay such total, together with any other charges, finance and/or collection, due thereon. A written estimate will be furnished upon request. Forms of payment accepted include Cash, Mastercard, Visa, American Express, Discover, Scratchpay, or Care Credit. Personal checks are not accepted as a form of payment.

Signature *