exoticsinformation "*" indicates required fields Date MM slash DD slash YYYY Client Name* Phone*Patient Name* Type of Animal* ADDITIONAL QUESTIONS REGARDING COVID19:Have you or anyone in your household experienced any cold or flu-like symptoms within the last 10 days? This includes the following symptoms: fever (at or over 100.4 F), chills, cough, shortness of breath/difficulty breathing, or new loss of taste or smell.* Yes No Have you or anyone in your household tested positive for COVID-19, or been exposed to anyone that has tested positive for COVID-19 within the last 10 days?* Yes No Are you currently on a quarantine or isolation order?* Yes No Are you fully-vaccinated against COVID19? Yes No While requesting vaccine status is well-established not to be a HIPAA violation, you may choose not to answer that question on our form. For the safety of our staff and others, in the event that a client declines to share their COVID-19 vaccine status, we work under the assumption that the individual is not vaccinated. When you come for your appointment, please be sure to wear a properly fitting mask over your mouth and nose during the entirety of your visit. Thank you.For further clarification on the law, please refer to the section titled “Is it a HIPAA Violation to Ask about COVID Vaccines?” at this link from the HIPAA Journal: https://www.hipaajournal.com/is-it-a-hipaa-violation-to-ask-for-proof-of-vaccine-status/.1. Have you or anyone in your household traveled either out-of-state or by plane within the past 14 days? Yes No 2. Have you or anyone in your household experienced any cold or flu-like symptoms recently? Yes No 3. Have you or anyone in your household tested positive for COVID19, or been exposed to anyone that has tested positive for COVID19? Yes No 1. Reason for visit:* 2. Duration of the problem:* 3. Has your pet been treated for this problem?* Yes No 4. If you answered yes, what treatment was given and how long ago, treating hospital name: 5. Has your pet had any medical problems? Is your pet taking any medications? List all: 6. If the problem is due to an injury, do you know the cause of the injury? 7. How long have you had your pet?* Where did you get pet from?* 8. How is your pet’s appetite?* Normal Decreased Not Eating How long? 9. How is your pet’s activity level?* Normal Lethargic Other How long? If Other, please explain: 10. How is your pet’s stool?* Normal Hard Soft Diarrhea How long? 11. How is your pet breathing?* Normal Labored Open Mouth Wheezing How long? Has it been getting worse since you noticed? 12. Is your pet coughing or sneezing?* Yes No How long? 13. Do your pet’s eyes appear normal?* Yes No How long? If no, please describe: 14. Does your pet’s nose appear normal?* Yes No How long? If no, please describe: 15. What do you feed your pet? Please list everything:* 16. Do you give any supplements? Please list all: 17. Describe your pet’s housing (cage, tank, etc.). Please list everything in pet’s environment (toys, bedding, what cage is made of, etc.):* 18. Where does your pet live?* Indoor Outdoor Both If both, what percentage indoor vs. outdoor? 19. (If Applicable) Does your pet have a heat and/or light source? Describe type, how many hours used and age of bulbs: 20. Are there any other pets in the house?* Yes No If yes, describe: 21. Are any other pets or persons showing signs of illness?* Yes No If yes, describe: 22. Where in the home is your pet’s cage located? Is it in front of or near a window or doorway?* 23. What do you clean your pet’s cage with? How often do you clean it?* 24. Does anyone in the house smoke?* Yes No 25. Do you use any items that have a non-stick surface (Teflon, Silverstone)?* Yes No 26. Do you use scented candles, plug-in air fresheners, etc.? Please describe: 27. What is the source of your pet’s drinking water?* Tap Bottled Other If other, please describe: 28. How often do you change your pet’s water? 29. Do you allow your pet to roam freely around the house?* Yes No Supervised 30. (If Applicable) Is your pet vaccinated? List all and when they were given: 31. (If Applicable) Has your pet had any vaccine reactions in the past? Yes No 32. Do you know the sex of your pet? How was the sex determined? Blood test Probe Egg Laying Other If other, please describe: 33. (If Applicable) Is your pet spayed/neutered?* Yes No If yes, when was it done? 34. (If Applicable) Does your pet have a history of egg laying? Yes No 35. Is your pet displaying any breeding behavior?* Yes No 36. (If Applicable) How is your pets color? Normal Darker Lighter 37. Is your pet on any flea control?* Yes No 38. Is your pet itchy? If so, how itchy on a scale 1-10 (1=not at all, 10= up all night scratching/chewing)?* 1 2 3 4 5 6 7 8 9 10 Any Additional Questions or Concerns:
