Client Registration and Patient Questionaire Form Tell Us About You!Owner's Name First Last Spouse, If Applicable: Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneMy Preferred Method Of Communication: Text Email Phone How Did You Hear About Us? Yelp Sign Referral Facebook Instagram Google Search Tell us about your pet! Patient InformationName:Breed:Year of Birth, or Age:Gender:Spayed/ Neutered:Microchipped:Color:Insured: Contact Number For Insurance: Previous Veterinary Health Care Providers: May We Contact Them For Record Requests: Yes No Patients Current Medications: Patients Current Diet: Brief Description Of Patients Current Living Environment: Reason For Appointment: Energy And Well-Being Please Select All That Apply:Energy Level In General Normal Reduced Increased Energy Is Highest Morning Afternoon Night Consistent Attitude/Mood Is Best Morning Afternoon Evening Night Consistent My Pet Is: Easily Excited (Eg. Papillon) Goal Driven (Eg. Border Collie) Dominant And Competitive (Eg. Jack Russell) Observant And Solitary (Eg. St. Bernard ) Friendly And Obedient (Eg. Labrador) My Pet Is: Happy Content Restless Crabby Depressed My Pet Prefers: To Be Cool To Be Warm Does Not Have A Preference Sleep Normal Decreased Increased Restless At Night Dreams None Vocalization Running MobilityMobility is best: Morning Afternoon Evening Night Consistent Mobility Level Normal Reduced Increased My pet has a specific area that is weak or lame Yes No If yes, please check all that apply: Front right leg Front left leg Back right leg Back left leg PainMy pet is in pain Yes No If you answered “Yes,” please complete the following regarding your pet’s pain:If Yes, How long? Pain is ___/10 with 10 being the worst How does the weather or temperature affect your pet’s pain? Is the pain in a specific area? (Please indicate yes, no, and where) After rest, the pain is: Better Worse After exercise, the pain is: Better Worse When does the pain get better? Better in morning Better in afternoon Better in evening No time difference NutritionWhich describes your pet's appetite? Normal Increased Decreased Which describes your pet eating habit: My pet loves to eat My pet is not food motivated My pet is picky DigestionIs your pet vomiting? No Occasionally A couple of times per week Often Other If vomiting is a regular occurrence, please describe when it happens and what it looks like: UrinaryPlease select all that apply to your pet's stools: normal soft diarrhea hard and dry constipation incontinent blood in the stool mucous in the stool Odor of stool Normal Strong No Odor Does your pet have gas? Yes No Thirst: Normal Increased Decreased Water Intake: Frequent small sips Large amounts at one time Moderate Urine: Normal Increased Decreased Incontinent Straining Vocalizes Color of Urine: Normal Clear Dark Yellow Odor of Urine: Normal No Odor Strong Odor Skin Select all that apply to your pet: Brittle nails Dry pads Dry skin with large flakes Dry skin with small flakes Is your pet itchy? Yes No If “Yes” please check all that apply: Sometimes During the day At night All the time Has your pet’s hair coat changed? Yes No If yes, please describe: Respiration/ BreathingMy pet’s voice or noises that he/she makes are: the same coughs have changed Please describe: Is there anything else we should know about your pet’s health or emotional history? Emergency Contacts In the case of a medical emergency, if I cannot be reached, I herby give the below person(s) permission to authorize Nautilus Pet Rehabilitation and/or Coast Veterinary to provide any medical treatment deemed necessary for my pet and permission for the doctor to treat to their best clinical judgment. I will be responsible for charges incurred in that treatment.Emergency Contact InformationName:Phone Number:Relationship to Owner: Consent and Social Media SharingI understand that payament is due in full at the time of service. We will gladly prepare a written treatment plan before services are rendered upon request. Yes No I Consent To Sharing My Pet On Social Media And Marketing Materials: Yes No Thanks for entrusting us with your four legged friends care. We consider it an honor and strive to provide the highest quality care available. Be sure to "like" us on Facebook or follow us on Instagram!
