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4176 Meridian Street

Bellingham, WA 98226

(360) 758-2200

24/7 Emergency Care

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Medical History Oncology Recheck Form

Medical History: Oncology Recheck (Bellingham)

4176 Meridian St, Bellingham, WA 98226 | Phone: 360-982-0166 | FAX: 1-888-867-6928 | bbvsh.com/bellingham | bellingham@bbvsh.com
Health Check
During the COVID-19 outbreak, the health and safety of our clients, patients, employees, doctors and our community is paramount.
Have you travelled to any countries outside the United States (including Canada) within the last 14 days?*

YesNo
Did you provide care or have close contact with a person with COVID-19 (probable or confirmed) while they were ill (cough, fever, sneezing, or sore throat) within the last 14 days?*

YesNo
Did you have close contact with a person who travelled outside of the United States in the last 14 days who has become ill (cough, fever, sneezing, or sore throat)?*

YesNo
Have you or anybody in your home had contact with someone who is being tested for COVID-19 or who has been diagnosed with COVID-19?*

YesNo
Contact Information
Your name*
Your email
Optional: If you enter in your email, we will send you a copy of this form to you.
Your pet's name*
Phone number where you can be reached today
(XXX) XXX-XXXX
Approximate time of pick-up (if you are dropping off)?
e.g. 4pm
Is there anything you would like to discuss with the oncologist today? Please note the oncologist will speak to you prior to treatment if there are any abnormalities on bloodwork or physical exam.*

Yes, prior to treatmentYes, at time of dischargeNo
Since your last visit...
Is your pet having difficulty breathing?*

YesNo
Has your pet’s appetite changed ?*

YesNo
How would you describe this change in appetite?

Increased appetite and/or thirstMildly decreased or needed coaxing to eatModerately decreased (3 days or less)Very decreased (3 days or more)Not eating, needed medical care
Has your pet had any vomiting?*

YesNo
How severe is the vomiting?

Mild: 1-2 episodes, only one dayModerate: 8 or fewer episodes, two days or lessSignificant: many episodes over several days, needed careSevere: required hospitalization
If medications were given for vomiting, what medications and which days?
Has your pet’s energy level or attitude changed?*

YesNo
How would you describe this change?

ImprovedMild lethargy or decreased activityLethargic for 3 or more daysVery lethargic, needed careSevere lethargy, required hospitalization
Has your pet had diarrhea?*

YesNo
How would you describe the diarrhea?

Mild: soft stools, no increased frequencyMild: soft stools with increased frequency or urgencyModerate: 3-5 episodes, needed medicationsSignificant: many episodes overseveral days, needed careSevere: required hospitalization
If medications were given for diarrhea, what medications and which days?
Is your pet coughing?*

YesNo
When did it start?
How often does it occur?
Has the coughing gotten better, worse, the same?

BetterWorseSame
Is your pet sneezing?*

YesNo
When did it start?
How often does it occur?
Has the sneezing gotten better, worse, the same?

BetterWorseSame
Is there nasal discharge?

YesNo
How would you characterize the discharge?
e.g. clear, green, bloody
Do you think your pet is in pain?*

YesNo
Where is the pain?
Is your pet drinking normally?*

YesNo
Are they drinking more or less?

MoreLess
Is your pet urinating normally?*

YesNo
Are they urinating more or less?

MoreLess
Is there blood in the urine?
Is your pet eating normally?*

YesNo
Are they eating more, less or not at all?

MoreLessNot at all
How long have they not been eating?
Has labwork or any other test been performed elsewhere since your last visit to Oncology?*

YesNo
Please list here:
Please list any medications your pet is taking (including non-prescription and supplements). Include name, strength (mg), how often, for how long.*
e.g. 'prednisone 5 mg tabs,½ tab once daily for 3 months' or N/A
Do you need refills of any medications?*

YesNo
Which ones?
OPTIONAL: HOW DID YOU FIND US?
We'd like to understand the specifics of how you discovered us during your time of emergency.
e.g. I searched Google for 24 hour emergency vet; My vet recommends you for emergencies, etc
Feedback on this form? Send your thoughts to marketing@bbvsh.com
Should be Empty:

Boundary Bay is a Veterinary Hospital in Bellingham providing advanced specialty care and 24/7 emergency veterinary services, giving pet owners peace of mind while supporting referring primary care veterinarians.

Bellingham Veterinary Specialty Hospital

4176 Meridian Street
Bellingham, WA 98226

P: (360) 758-2200
F: 1 (888) 867-6928
E: bellingham@bbvsh.com

Web: bellingham.bbvsh.com

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