{"id":352,"date":"2020-12-10T14:56:02","date_gmt":"2020-12-10T19:56:02","guid":{"rendered":"https:\/\/www.shoemakervet.com\/?page_id=352"},"modified":"2020-12-10T14:56:03","modified_gmt":"2020-12-10T19:56:03","slug":"visit-questionnaire","status":"publish","type":"page","link":"https:\/\/www.shoemakervet.com\/visit-questionnaire\/","title":{"rendered":"Visit Questionnaire"},"content":{"rendered":"<script type=\"text\/javascript\">var 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#112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_4' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_4' id='gform_4'  action='\/wp-json\/wp\/v2\/pages\/352#gf_4' data-formid='4' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_4_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_1\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Client&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_1'>\n                            \n                            <span id='input_4_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_4_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_4_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_4_2\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_2\" ><label class='gfield_label gform-field-label' for='input_4_2'>Pet&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_4_2' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_5\" ><label class='gfield_label gform-field-label' >Species<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_5'>\n\t\t\t<li class='gchoice gchoice_4_5_0'>\n\t\t\t\t<input name='input_5' type='radio' value='Dog'  id='choice_4_5_0'    \/>\n\t\t\t\t<label for='choice_4_5_0' id='label_4_5_0' class='gform-field-label gform-field-label--type-inline'>Dog<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_5_1'>\n\t\t\t\t<input name='input_5' type='radio' value='Cat'  id='choice_4_5_1'    \/>\n\t\t\t\t<label for='choice_4_5_1' id='label_4_5_1' class='gform-field-label gform-field-label--type-inline'>Cat<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_5_2'>\n\t\t\t\t<input name='input_5' type='radio' value='Other'  id='choice_4_5_2'    \/>\n\t\t\t\t<label for='choice_4_5_2' id='label_4_5_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_3\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_3\" ><label class='gfield_label gform-field-label' for='input_4_3'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_4_3' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_6\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_6\" ><label class='gfield_label gform-field-label' for='input_4_6'>What problem(s) are your pet experiencing?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_4_6' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_7\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_7\" ><label class='gfield_label gform-field-label' for='input_4_7'>When did the problem start?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_4_7' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_8\" ><label class='gfield_label gform-field-label' >Has problem changed?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_8'>\n\t\t\t<li class='gchoice gchoice_4_8_0'>\n\t\t\t\t<input name='input_8' type='radio' value='Improved'  id='choice_4_8_0'    \/>\n\t\t\t\t<label for='choice_4_8_0' id='label_4_8_0' class='gform-field-label gform-field-label--type-inline'>Improved<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_8_1'>\n\t\t\t\t<input name='input_8' type='radio' value='No Change'  id='choice_4_8_1'    \/>\n\t\t\t\t<label for='choice_4_8_1' id='label_4_8_1' class='gform-field-label gform-field-label--type-inline'>No Change<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_8_2'>\n\t\t\t\t<input name='input_8' type='radio' value='Worse'  id='choice_4_8_2'    \/>\n\t\t\t\t<label for='choice_4_8_2' id='label_4_8_2' class='gform-field-label gform-field-label--type-inline'>Worse<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_9\" ><label class='gfield_label gform-field-label' >Has a similar problem happen in the past?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_9'>\n\t\t\t<li class='gchoice gchoice_4_9_0'>\n\t\t\t\t<input name='input_9' type='radio' value='Yes'  id='choice_4_9_0'    \/>\n\t\t\t\t<label for='choice_4_9_0' id='label_4_9_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_9_1'>\n\t\t\t\t<input name='input_9' type='radio' value='No'  id='choice_4_9_1'    \/>\n\t\t\t\t<label for='choice_4_9_1' id='label_4_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_10\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_10\" ><label class='gfield_label gform-field-label' for='input_4_10'>Are any medications or supplements being administered?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_4_10' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_11\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_11\" ><label class='gfield_label gform-field-label' for='input_4_11'>What is the pet&#039;s current diet and feeding schedule including treats?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_4_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_12\" ><label class='gfield_label gform-field-label' >Eating Changes?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_12'>\n\t\t\t<li class='gchoice gchoice_4_12_0'>\n\t\t\t\t<input name='input_12' type='radio' value='Increased'  id='choice_4_12_0'    \/>\n\t\t\t\t<label for='choice_4_12_0' id='label_4_12_0' class='gform-field-label gform-field-label--type-inline'>Increased<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_12_1'>\n\t\t\t\t<input name='input_12' type='radio' value='Decreased'  id='choice_4_12_1'    \/>\n\t\t\t\t<label for='choice_4_12_1' id='label_4_12_1' class='gform-field-label gform-field-label--type-inline'>Decreased<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_12_2'>\n\t\t\t\t<input name='input_12' type='radio' value='No Change'  id='choice_4_12_2'    \/>\n\t\t\t\t<label for='choice_4_12_2' id='label_4_12_2' class='gform-field-label gform-field-label--type-inline'>No Change<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_13\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_13\" ><label class='gfield_label gform-field-label' for='input_4_13'>When was your pets last vaccines?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_4_13' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_14\" ><label class='gfield_label gform-field-label' >Any change in weight?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_14'>\n\t\t\t<li class='gchoice gchoice_4_14_0'>\n\t\t\t\t<input name='input_14' type='radio' value='Increased'  id='choice_4_14_0'    \/>\n\t\t\t\t<label for='choice_4_14_0' id='label_4_14_0' class='gform-field-label gform-field-label--type-inline'>Increased<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_14_1'>\n\t\t\t\t<input name='input_14' type='radio' value='Decreased'  id='choice_4_14_1'    \/>\n\t\t\t\t<label for='choice_4_14_1' id='label_4_14_1' class='gform-field-label gform-field-label--type-inline'>Decreased<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_14_2'>\n\t\t\t\t<input name='input_14' type='radio' value='No Change'  id='choice_4_14_2'    \/>\n\t\t\t\t<label for='choice_4_14_2' id='label_4_14_2' class='gform-field-label gform-field-label--type-inline'>No Change<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_15\" ><label class='gfield_label gform-field-label' >Any increase or decrease in water consumption?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_15'>\n\t\t\t<li class='gchoice gchoice_4_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Increased'  id='choice_4_15_0'    \/>\n\t\t\t\t<label for='choice_4_15_0' id='label_4_15_0' class='gform-field-label gform-field-label--type-inline'>Increased<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='Decreased'  id='choice_4_15_1'    \/>\n\t\t\t\t<label for='choice_4_15_1' id='label_4_15_1' class='gform-field-label gform-field-label--type-inline'>Decreased<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_15_2'>\n\t\t\t\t<input name='input_15' type='radio' value='No Change'  id='choice_4_15_2'    \/>\n\t\t\t\t<label for='choice_4_15_2' id='label_4_15_2' class='gform-field-label gform-field-label--type-inline'>No Change<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_16\" ><label class='gfield_label gform-field-label' >Any change in urination or bowel movements?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_16'>\n\t\t\t<li class='gchoice gchoice_4_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='Increased'  id='choice_4_16_0'    \/>\n\t\t\t\t<label for='choice_4_16_0' id='label_4_16_0' class='gform-field-label gform-field-label--type-inline'>Increased<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='Decreased'  id='choice_4_16_1'    \/>\n\t\t\t\t<label for='choice_4_16_1' id='label_4_16_1' class='gform-field-label gform-field-label--type-inline'>Decreased<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_16_2'>\n\t\t\t\t<input name='input_16' type='radio' value='Blood'  id='choice_4_16_2'    \/>\n\t\t\t\t<label for='choice_4_16_2' id='label_4_16_2' class='gform-field-label gform-field-label--type-inline'>Blood<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_16_3'>\n\t\t\t\t<input name='input_16' type='radio' value='Straining'  id='choice_4_16_3'    \/>\n\t\t\t\t<label for='choice_4_16_3' id='label_4_16_3' class='gform-field-label gform-field-label--type-inline'>Straining<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_16_4'>\n\t\t\t\t<input name='input_16' type='radio' value='No Change'  id='choice_4_16_4'    \/>\n\t\t\t\t<label for='choice_4_16_4' id='label_4_16_4' class='gform-field-label gform-field-label--type-inline'>No Change<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_17\" ><label class='gfield_label gform-field-label' >Current preventatives?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_17'>\n\t\t\t<li class='gchoice gchoice_4_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Yes'  id='choice_4_17_0'    \/>\n\t\t\t\t<label for='choice_4_17_0' id='label_4_17_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='No'  id='choice_4_17_1'    \/>\n\t\t\t\t<label for='choice_4_17_1' id='label_4_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_18\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  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gchoice_4_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='Yes'  id='choice_4_19_0'    \/>\n\t\t\t\t<label for='choice_4_19_0' id='label_4_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='No'  id='choice_4_19_1'    \/>\n\t\t\t\t<label for='choice_4_19_1' id='label_4_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_20\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_20\" ><label class='gfield_label gform-field-label' for='input_4_20'>Additional Information<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input 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