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Griffith Small Animal Hospital - Patient Health Questionnaire
1
Patient Health Questionnaire
First Name
Last Name
Pet’s Name
Email
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2
What is your reason for today's visit?
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3
Are Vaccines Current?
Yes
No
I don't know
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4
Heartworm Prevention Given on
Date
Month
Day
Year
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5
Flea/Tick Prevention Given on
Date
Year
Month
Day
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6
Type of Food and Amount at each feeding?
Yes
No
Yes
No
Do you need any medication refills?
Current Phone Number for Consult and Estimate Approval
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