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

MailEmailPhone
Has there been a change in your pet's condition since their last visit?

Yes, there has been a new symptom or a change with my petNo, everything has stayed the same with my pet and I have no questions or concerns
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?

IndoorOutdoorFamily PetPerformanceHuntingShowBreedingServiceBoardingDaycareTravelingDog Events
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?

YesNo
Are They Normal and Healthy?

YesNo
If No, What Symptoms
Nutrition and Medications
Primary Diet
Amount and Frequency
Did You Recently Change Diets?

YesNo
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?
YesNo
If yes, What is the Name and Phone of the Clinic?
May we request records from them?

YesNo
Does Your Pet Have Health Insurance?
If Yes, What Company?
Policy #
If No, Are You Interested in Pet Insurance?

YesNo
Do You Need Any of the Following?
VaccinesMedicationsFoodMicrochipFecal TestHeartworm TestHeartworm PreventativeFlea and TickNail TrimEmpty Anal Sacs
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:

ImprovingDecliningStaying the Same
Has Your Pet Been Treated for This Before?

YesNo
If Yes, What Was The Treatment and Response
How is Your Pet Acting?

NormalQuieterMore ActiveWeakPainfulUnable to Walk or MoveWalking DifferentlyAbdomen Enlarged
If Behavior has Changed Please Describe
Is Your Pet Drinking?

NormalNothingLessMore
If Drinking is Abnormal Please Describe
Is Your Pet Eating?

NormalNothingLessMoreOnly Treats or Human Food
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?

YesNo
If Yes, How Often
What Does the Vomit Look Like
Is Your Pet Having Stools?

NormalNoneMore FrequentLess FrequentDiarrheaSoftWateryLarge StoolSmall StoolStrainingHardNormal ColorBloodMucus
If Stools are Abnormal Please Describe
Change in Weight?

SameGainedLost
If Your Pet Has a Change in Weight Please Describe
Is Your Pet Urinating?

NormalNothingLessMoreBloodStrainingAccidentsDribblingIncontinence
If Urination is Abnormal Please Describe
How is Your Pet Breathing?

NormalFasterSlowerChange in CharacterHard to BreathePantingCoughingSneezingWheezingNasel Discharge
If Breathing is Abnormal Please Describe
Eyes

NormalRedDischargeSquintingRubbingPainfulProtrudingChange in Color
If Eyes are Abnormal Please Describe
Ears

NormalRedDischargeRubbingPainfulOdor
If Ears are Abnormal Please Describe
What medications have you used before, if any, for ear treatment?
Skin

NormalRedRashHair LossFleasTicksLumpsWoundsScratchingBitingRecurrent
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?

NormalPainLimping
If there is Pain Please Describe
Behavior

NormalAnxietyOther
If there is a Change in Behavior Please Describe
Reproductive Organs

NormalPainSwellingLumpsRecent BreedingDischarge from Genitals
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