Behavior Recheck Questionnaire

"*" indicates required fields

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 First Name*

Client's Last Name*

Best Contact Number*

Email*

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:

Worse
<25% improvement
25-50% improvement
50-75% improvement
>75% improvement

Frequency

Worse
<25% improvement
25-50% improvement
50-75% improvement
>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?

Moved to a new house?

New pet added?

Death or relinquishment of another pet?

Death of a household member?

Change in household schedule? (change/lost job, school, etc)

Other?

Check all that apply

Any other concerns you would like to discuss?

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Name

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What's Next

1
Call us or schedule an appointment online.
2
Meet with a doctor for an initial exam.
3
Put a plan together for your pet.

Make An Appointment

What's Next

Call us or schedule an appointment online.

Meet with a doctor for an initial exam.

Put a plan together for your pet.

Where family pets find loving care