Wasatch Hollow Animal Hospital - Medical Concern Recheck Form

Please complete this form as thoroughly as possible so our team can compare your pet's progress and keep your visit efficient.

Client Name

Pet name

Date

MM slash DD slash YYYY

Phone

Email

Species

Breed

Age

Sex

Weight

Doctor/Team

Reason for recheck / follow-up

What are we rechecking today?

Since the last visit, is your pet:

Better

Worse

Same

Resolved

Comes and goes

Unsure

Concerns for today

No new concerns

Original concern not improving

Getting worse

New concern

Medication/treatment concern

Other

Briefly explain any concerns:

Treatment / medications since last visit

Were medications, treatments, diet changes, rest restrictions, or other instructions followed?

Yes

Mostly

No

No medications/treatments prescribed

Any missed doses, trouble giving medication/treatment, or side effects?

No

Missed doses

Trouble giving

Possible side effects

Unsure

Details

Current symptoms - check any that apply

Decreased/not eating

Drinking changed

Low energy

Painful/restless

Diarrhea

Vomiting

Coughing/sneezing

Urination issue

Stool issue

Pain/limping

Itching/ears/skin

Wound/lump change

Behavior change

Other

No current symptoms

Details / changes since last visit:

Refills / final notes

Do you need refills today?

Yes

No

Unsure

Medication/refill details

Is there anything else you want the doctor to know before your appointment?