Exam Form

Appointment Questionnaire

for your pet's upcoming visit to Veterinary Village
Name
Street Address
City
State
Zip Code
Email
example@example.com
Phone 1
Phone 2
Phone 3
Phone 4
Patient Name
Breed
Age/Birthdate

MonthDayYear
Date
Preferred Contact Method
Has there been a change in your pet's condition since their last visit?
Since there has been no change in your pet's condition since their last visit you can type your name and the date below to acknowledge receipt of this form.

If there has been a change, a new symptom, or you have questions, please select YES to the question above and fill out the form that appears.
Sign:
Date:

MonthDayYear
Date
History:
Your Pet's Lifestyle
What is Your Pet's Lifestyle?
If Your Dog is Boarded, or Goes to Daycare, Where Do They Go?
If Your Dog Participates in Events, What Kind?
Other Pets in the Household
Do You Have Other Pets?
Are They Normal and Healthy?
If No, What Symptoms
Nutrition and Medications
Primary Diet
Amount and Frequency
Did You Recently Change Diets?
If Yes, When?
Treats and Snacks

0/70
Current Medications
Flea & Tick
Heartworm
Prescriptions

0/80
Over the Counter (including joint supplements and CBD oil)
Does Your Pet Have Allergies?
Food
Medication
Vaccines
Has Your Pet Been to Another Veterinarian?
If yes, What is the Name and Phone of the Clinic?
May we request records from them?
Does Your Pet Have Health Insurance?
If Yes, What Company?
Policy #
If No, Are You Interested in Pet Insurance?
Do You Need Any of the Following?
Symptoms and Reason for Visit
What do you want to talk to the Doctor about?
What specific health concerns do you want examined or discussed?
IF sick or hurt, when was your pet last normal?

0/85
What Symptoms Did You Notice First and When?

0/85
Is Your Pet's Condition:
Has Your Pet Been Treated for This Before?
If Yes, What Was The Treatment and Response
How is Your Pet Acting?
If Behavior has Changed Please Describe
Is Your Pet Drinking?
If Drinking is Abnormal Please Describe
Is Your Pet Eating?
What and When Did Your Pet Last Eat
Did Your Pet Eat Anything Out of the Ordinary or that He/She Should Not Have?
Is Your Pet Vomiting?
If Yes, How Often
What Does the Vomit Look Like
Is Your Pet Having Stools?
If Stools are Abnormal Please Describe
Change in Weight?
If Your Pet Has a Change in Weight Please Describe
Is Your Pet Urinating?
If Urination is Abnormal Please Describe
How is Your Pet Breathing?
If Breathing is Abnormal Please Describe
Eyes
If Eyes are Abnormal Please Describe
Ears
If Ears are Abnormal Please Describe
What medications have you used before, if any, for ear treatment?
Skin
If the Skin is Abnormal Please Describe
If there are Sores, Hair Loss or Lumps Where are they Located?
When did the Symptoms Start? Age and Time of Year
Pain in Legs/Back/Neck?
If there is Pain Please Describe
Behavior
If there is a Change in Behavior Please Describe
Reproductive Organs
If any Abnormalities in Reproductive Organs Please Describe
If Spayed or Neutered, What Age Was it Done?
If Not Spayed, When was Her Last Heat Cycle?
Plans to Breed?
Other Concerns or Observations?

0/85
Should be Empty:

Appointment Questionnaire

Since there has been no change in your pet's condition since their last visit you can type your name and the date below to acknowledge receipt of this form.

If there has been a change, a new symptom, or you have questions, please select YES to the question above and fill out the form that appears.

History:

Your Pet's Lifestyle

Other Pets in the Household

Nutrition and Medications

Current Medications

Does Your Pet Have Allergies?

Has Your Pet Been to Another Veterinarian?

Does Your Pet Have Health Insurance?

Do You Need Any of the Following?

Symptoms and Reason for Visit