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Appointment questionnaire
Today's date
*
Date Format: MM slash DD slash YYYY
Pet's name
*
Who will be bringing your pet to the appointment? If this person is not the owner or co-owner authorized in your pet's medical record, we will need to reschedule the appointment.
*
Best phone number to reach you
*
Reason for visit?
*
Do you have pet insurance?
*
Yes
No
Interested
Does your pet experience any stress, anxiety or fear when visiting the veterinary hospital? If yes, please explain.
General concerns
Please check all that apply.
Is your pet experiencing any of the following symptoms?
*
Coughing or sneezing
Vomiting or diarrhea
Change in appetite or thirst
Changes in urinating and defecating habits
Constipation or difficulty defecating
Scooting
Observed lumps, bumps or masses
Observed scratching or licking
Soreness or stiffness
Change in mobility
Notable change in weight
None of the above
Please elaborate on the checked boxes.
Any other concerns or issues not listed above?
What diet, and how much, are you currently feeding your pet?
*
List all treats and/or human food your pet receives in a day.
*
Do you perceive your pet to be overweight?
*
Yes
No
Uncertain
Is your pet taking heartworm and internal parasite prevention monthly year-round?
*
Yes
No
When was the last dose given?
Is your pet taking flea and tick prevention monthly year-round?
*
Yes
No
When was the last dose given?
Is your pet currently taking any other medication or natural supplement?
*
Yes
No
If the above answer was "yes" please indicate all medications being given, including dosage and frequency. Please elaborate on reason for giving.
Please help us understand your pet's lifestyle. Please check all that apply.
*
Goes in the backyard only
Roams freely
Hunts small mammals
Goes for walks on streets only
Stays strictly indoors
Goes to dog parks
Goes hiking in the woods
Goes swimming
Goes to a cottage
Visits the groomer
Goes to a boarding facility
Travels with me to southern states in the winter
Dental concerns
Please check all that apply.
Is your pet experiencing any of the following symptoms?
*
Bad breath
Redness of the gums
Difficulty eating or chewing
Dropping food
Pawing at the mouth
Unusual drooling
Visible changes in the mouth
Swelling around the muzzle or below the eyes
None of the above
Please elaborate on the checked boxes.
What type of home oral care do you provide for your pet
*
Daily brushing
Dental diet
HealthyMouth water additive
VOHC approved dental chews
Other
None of the above
Please check all that apply.
Behaviour concerns
Please check all that apply.
Is your pet experiencing any of the following symptoms?
*
Increased anxiety, fear, and/or stress
House soiling
Increased irritability or aggression
Decreased tolerance of handling
Repetitive behaviours like pacing or excessive grooming
Decreased grooming or self-care
Separation anxiety
None of the above
Please elaborate on the checked boxes.
Any other concerns or issues not listed above?
Aging related concerns
Please check all that apply.
Is your pet experiencing any of the following symptoms?
*
Decreased awareness or confusion
Decreased recognition of people or animals
Decreased affection or interaction with you or loved ones
Loss of hearing or sight
Muscle tremors or shaking
Weakness or incoordination
Difficulty climbing stairs
Decreased activity or increase in sleep
Excessive vocalization
None of the above
Please elaborate on the checked boxes.
Any other concerns or issues not listed above?
Clients
What to Expect
Take A Tour
Our Philosophy of Care
Our Hospital
Location & Hours
Team
FAQ’s
Services
Wellness and Vaccination Programs
Medical Services
Surgical Services
Anesthesia and Patient Monitoring
Pain Management and Control
Microchip Pet Identification
Pet Supplies
Additional Services
Feline Friends
Illustrated Articles
How-To Videos
Pet Health Checker
News
FAQ’s
Canine Companions
MyPetED
Diseases and Conditions
Fun Stuff for all ages
Forms
Dental Surgery Consent Form
Contact Us