Foster Care Pre-Visit Questionnaire Foster Pre-Visit Questionnaire Foster Parent Name First Last Phone NumberEmail Pet(s) Name Shelter Buddy IDWhat are your medical concerns today?(Required) When did you first notice these symptom(s)? How is their energy level? Bright Alert Responsive Quiet Alert Responsive Lethargic Most recent temperature(s) – fever, cold, etc.: How is their appetite/thirst?(Required) Most recent weight and when:(Required) Is this an unexpected increase or decrease in weight? Yes No Any vomiting or diarrhea?(Required) Yes No When did it start?(Required) How often is the vomiting/diarrhea?(Required) What is the color and consistency of vomit/stool?(Required) Any blood, tarry, or coffee ground appearance?(Required) Yes No Any salmon or trout exposure in last two weeks (dogs)?(Required) Any coughing or sneezing?(Required) Yes No When did it start?(Required) Is the cough productive?(Required) Yes No N/A What is the color and consistency of nasal and/or eye discharge? Any labored/distressed breathing or collapsing? Yes No Current diet, including treats and people food:(Required) Current medications & supplements:(Required) Do you need medication refills?(Required) Yes No Do you need flea medication or dewormer?(Required) Yes No Any known allergies:(Required) Foster Specific Questions:If applicable, are any littermates having similar symptoms? Are any other animals in your home having similar symptoms? How long has the animal been in your care?(Required) Is your foster animal returning to shelter for adoption at this visit?(Required) Yes No Do you need any additional supplies for continuing foster?(Required) Yes No Any Additional Information Will you be staying on site for your pet's appointment?(Required) Yes No If not, preferred pickup time: Phone number where you can be reached:(Required)Date
