Appointment questionnaire

Today's date*

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?*

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.*

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?*

Please elaborate on the checked boxes.

Any other concerns or issues not listed above?

Monday	8:00am – 5:00pm
Tuesday	8:00am – 5:00pm
Wednesday	8:00am – 5:00pm
Thursday	8:00am – 5:00pm
Friday	8:00am – 5:00pm
Saturday	Closed
Sunday	Closed

General concerns

Dental concerns

Behaviour concerns

Aging related concerns

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