SVH Questionnaire
Date of Appointment
*
-
Month
-
Day
Year
Date
Client Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Pet Name
*
What is the primary reason for the visit?
*
What are the symptoms?
*
When did you first notice the problem?
*
Is this the first time your pet has had this problem? If no, list the dates of other occurrences.
*
Is the activity level normal?
*
Yes
No
Eating and drinking normally?
*
Yes
No
Did your pet eat today?
*
Yes
No
If yes, at what time?
How much food did your pet eat?
Does your pet receive any treats?
*
Yes
No
If yes, what kind of treats do you feed your pet?
Is your pet vomiting?
*
Yes
No
If yes, how often? How long after eating? What does it look like?
Any diarrhea or constipation?
*
Yes
No
If yes, how often? What does the stool look like? Is there any blood?
Any coughing?
*
Yes
No
If yes, how often and for how long? Does your pet cough anything up?
Any sneezing?
*
Yes
No
Any changes in mobility?
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Yes
No
If yes, please describe.
Any limping or lameness?
*
Yes
No
If yes, please describe and state where.
Urinating normally?
*
Yes
No
If no, what is abnormal? Any accidents in the house?
Does your pet seem itchy?
*
Yes
No
If yes, on a scale of 1-10, 1 being less itchy and 10 being unbearably itchy, how itchy is your pet?
Any fur loss noted?
*
Yes
No
If yes, where?
Any discharge from the eye(s)?
*
Yes
No
If yes, which eye(s)?
Any discharge from the nose?
*
Yes
No
What medication(s) is your pet receiving and how often?
*
Was any medication administered this morning? If yes, what medication(s) and at what time(s)?
*
Is your pet receiving heartworm prevention? If yes, which preventative is your pet on?
*
Is your pet receiving flea and/or tick prevention? If yes, which preventative is your pet on?
*
Do you have any other health or behavioral concerns that you would like to discuss with the Doctor?
*
Yes
No
If yes, what other health or behavioral concerns do you have?
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