Case Intake Form
Questions marked by * are required.
1.
Your Name: *
2.
Your E-mail Address: *
3.
Your city and state: *
4.
Your phone number: *
5.
Animal Type (Canine, Horse, Feline, Other): *
6.
Animal age (in years): *
7.
Animal sex: *
8.
When was the animal's last visit to a D.V.M.? *
9.
What form of cancer or chronic illness is it? *
10.
What's the D.V.M.'s prognosis? *
11.
How long ago did you first start to notice symptoms in the animal? *
12.
Tell me about the present condition and vitality of the animal. Is it walking? Eating? In pain? Lying around waiting to die? *
13.
Tell me about the animal's normal personality and behaviors. It is normally aggressive? Destructive? Timid? Playful? What does it do all day normally? *
14.
Now, what were the first mental symptom changes noted in the animal that seemed striking, odd, and unusual enough to worry? Did the animal just hide somewhere in solitude and want to die? Was it whimpering for help? Anxious? Restless? Lethargic? Unusually depressed? *
15.
What kind of breed are we dealing with here? Tell me also all about this animal's diet ever since owned. *
16.
How much does the animal weigh now? How much did it weigh when last healthy and when was that? *
17.
Tell me about any unusual, odd, and striking discharges from the animal. Bad breath? Breath that smells like what? Foaming at the mouth? Belching? Flatulence with no foul odor? Flatulence with horrible odor? What color and constiency to the stool? Any bowel control problems? What color to the urine? Any stench to the urine? Any oddity in urinary flow, frequency, or control? How about respiration? Is it normal? Slow? Unusually fast with panting? Is the dog easily winded? Any external or internal bleeding present? *
18.
Are the tumors hard and stony or soft and pus-like? *
19.
Is there a history of famililal cancer in the dog's pack? *
20.
Tell me about this dog's medical history, vaccination history, symptom and pathology history (Here, give me the names D.V.M.'s have given): *
21.
Okay, now, in your own words describe to me the worst symptom or condition that YOU observe in the animal. I don't want to hear disease names and theories; Just the facts; Just what you see in regard to the most severe symptoms in the animal. Forgetting the cancer or ailment names, if you could cure only 3 sufferings in this animal right now, what would they be and list them in priority order? *
22.
Is there anything which seems to make any of those symptoms worse? What? When? How? *
23.
Is there anything which makes those symptoms better? What? When? How? *
24.
List the present medications this animal is under: *
25.
In your best estimate or that of the vet, about how long does this animal have to live? *
26.
For the next week, will you be available by email or telephone? When is the best time to reach you by phone? *
27.
ELECTRONIC SIGNATURE: By initialling this box and submitting this form, you agree that you have read the SB577, Practice Style & Disclosures section, Billling & Fees section, and agree to the Liability Waiver & Legal Releases on the provided website. *