Please note: We will be closed from Saturday, December 24th through Monday, December 26th in observance of Christmas!

Behavior Recheck Questionnaire

Please fill out this questionnaire as completely as possible. If you have any questions or need clarification on any of the choices, please contact us. As always, thank you for entrusting us with your pet’s care!

Client's Name *

First

Last

Best contact number: *

Pet's Name *

What are your goals for this recheck consultation? Please be specific.

What medications is your pet on? For behavior medications, please list current dose (mg strength) and frequency. Please include if your pet was prescribed additional behavioral medications that they are no longer taking or behavioral medications that are not given on a consistent every day basis.

Has your pet experienced any side effects from their behavioral medications?

Please list your pet’s current issues and indicate whether they are pre-existing or new since your last visit. For pre-existing issues, please note what changes there have been. Pre-existing issues-for each problem, rank the change in intensity and frequency according to the following scale:
Intensity:
1. Worse
2. <25% Improvement
3. 25-50% Improvement
4. 50-75% Improvement
5. >75% Improvement

Frequency:
1. Worse
2. <25% Improvement
3. 25-50% Improvement
4. 50-75% Improvement
5. >75% Improvement

List your pet’s current issues and indicate whether they are pre-existing or new since your last visit. For pre-existing issues, please note what changes there have been (using the scale above). For new issues, please note when the behavior started and the severity of the problem (not serious, fairly serious, very serious)

Have any of the following changes occurred since our last visit? (check all that apply)

Any other concerns you would like to discuss?

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