Behavioral Recheck
Owner Information
First Name
Last Name
Email
Phone
Has your address changed since the last consultation
Yes
No
If so, please provide your updated address below:
Date of your pet's behavioral recheck
Your primary care veterinarian's name, clinic name and phone number:
Pet Information
Pet's Name
Pet's Date of Birth (mm/dd/yyyy)
Pharmacy Information
Preferred Local Pharmacy
Pharmacy Phone Number
Recent Medical History (Since Last Consultation)
Has your pet had any blood or lab work completed since the last appointment last appointment?
Yes
No
If so, please list below and
have your veterinarian forward those results to
lsinndvm@gmail.com
Has your pet developed any medical problems since the last appointment (e.g., seizures, allergies)?
Yes
No
If so, please list them:
Please list all medications
including dose and frequency
that your pet is
currently
taking:
If your pet was placed on medication for behavior problems, do you think the medication helped?
Yes
No
n/a
If yes, please estimate the percent improvement (%):
Have you noticed any side effects with medication?
Yes
No
n/a
If yes, please describe:
Does your pet have any food restrictions?
Management and Training
Has your household changed since your last appointment (new house, marriage, children, pets, etc.)?
Yes
No
If yes, please describe:
Has the typical 24-hour day in the life of your pet changed since your last appointment?
Yes
No
If so, please describe:
How much and what kind of exercise does your pet get over the course of an average week?
Have you done any training with your pet since your last visit?
Yes
No
If so, please describe the training and how successful it was:
Progress and Goals
How do you feel your pet is progressing?
Have any new behaviors/concerns arisen since your pet's last appointment?
What are your goals for this consultation?
How many current behavioral problems are you concerned about?
Please select...
1
2
3
4
Behavioral Problem #1
Please describe the behavioral problem:
How has this behavior changed since your pet's last appointment?
Better
Worse
Unchanged
Since your last visit, what have you done to try to change this behavior?
What has been least successful?
What has been most successful?
Has anything you've done since the last visit made the behavior worse?
Behavioral Problem #2
Please describe the behavioral problem:
How has this behavior changed since your pet's last appointment?
Better
Worse
Unchanged
Since your last visit, what have you done to try to change this behavior?
What has been least successful?
What has been most successful?
Has anything you've done since the last visit made the behavior worse?
Behavioral Problem #3
Please describe the behavioral problem:
How has this behavior changed since your pet's last appointment?
Better
Worse
Unchanged
Since your last visit, what have you done to try to change this behavior?
What has been least successful?
What has been most successful?
Has anything you've done since the last visit made the behavior worse?
Behavioral Problem #4
Please describe the behavioral problem:
How has this behavior changed since your pet's last appointment?
Better
Worse
Unchanged
Since your last visit, what have you done to try to change this behavior?
What has been least successful?
What has been most successful?
Has anything you've done since the last visit made the behavior worse?
Do you have any final concerns or questions about your pet that have not been covered by this questionnaire?
Contact Information