Stoney Creek - Examination Questionnaire

1

Examination Questionnaire

Thank you for continuing to be a part of the Animal Hospital of Stoney Creek family! We are working hard to ensure that your furry family member still receives the best care possible. In order to facilitate your visit, we ask that you complete this short questionnaire prior to arriving for your appointment.

We appreciate you taking the time to fill this out so that we can make sure we are doing the very best for your furry baby!

Thanks so much!
Sincerely,
The Doctors and Staff of the Animal Hospital of Stoney Creek
* Required

2

Please enter your and your pet's names* This field is required.

Your Name

Pet's Name (If you have multiple pets , separate them with a comma)

3

Have you or anyone in your household had any contact with COVID-19 or have related symptoms such as fever, cough, or shortness of breath? * This field is required.

4

Have you noticed your pet sneezing, coughing or any changes in your pet's breathing?* This field is required.

Yes, please describe in Next question

No, skip to Next question

5

Please describe any sneezing or coughing you have observed

6

Does your pet have any vomiting, diarrhea or changes in appetite?* This field is required.

Yes, please describe in Next question

No, skip to Next question

7

Please describe any changes in eating, vomiting or stools

8

Do you have any concerns about the health of your pet’s teeth or breath?* This field is required.

Yes, please describe in Next question

No, skip to Next question

9

Please describe any concerns you have with your pet's teeth, breath or mouth

10

Do you have any concerns with your pet's drinking or urination? * This field is required.

Yes, please describe in Next question

No, skip to Next question

11

Please describe any changes in drinking or urination

12

Do you have any concerns about your pet’s skin or coat? * This field is required.

Yes, please describe in Next question

No, skip to Next question

13

Please describe any concerns with your pet's skin or coat

14

Do you have any pictures of specific areas or lesions that you are concerned about?

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

15

Is your pet experiencing any issues with mobility? Is jumping on the bed, couch or into the car an issue? Have you noticed any limping or pain?* This field is required.

Yes, please describe in Next question

No, skip to Next question

16

Please describe any changes in your pet's mobility or ability to get around

17

Are there any new lumps or bumps that concern you? * This field is required.

Yes, please describe in Next question

No, skip to Next question

18

Please describe when you first noticed them, what they looked like and if they have changed.

19

Do you have any pictures of growths or lumps you would like us to see?

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

20

Is there anything else you feel is important that we know prior to examining your pet?

Do you need food or a refill of any long term medications while here for your appointment?

What number can we reach you at while we are examining your pet?

What food does your pet eat? How much do you feed?

21

Do you have Pet insurance?

If no - are you interested in receiving more information about insurance?

If yes - what company is your pet insured thorough?

22

We understand that sometimes life can be unpredictable. If you are unable to make it to your appointment, or are going to be late, please call the office at (905) 662-3033 to reschedule.

23

Owner Email* This field is required.

example@example.com