Town & Country Animal Hospital Pet Examination Questionnaire
***If you are coming in for a Tech Appt, (NON Dr. APPT) you do not need to fill out this questionnaire.***
Name
*
First Name
Last Name
Spouse's name or partner's name to be added to your account
First Name
Last Name
Email to link to your pet's medical record.
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Spouse or partner's phone number
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet's Name
*
Is this our first time seeing your pet?
*
Yes
No
If yes, where has your pet been seen prior to this visit?
For Dogs Only- Have you seen wildlife (raccoons, opossums, rats, mice, foxes or skunks) anywhere your dog spends time outdoors?
*
Yes
No
For dog owners- Does your Dog come in contact with other dogs....
*
While at home
While boarded at a kennel facility
While professionally groomed
While bathed
While at a dog park
While at dog shows
I don't have dogs
For Cats only- My cat spends most of the time...
*
Indoors only
Outdoors
Indoors & Outdoors equally
I don't have cats
For Cats only- My cat comes in contact with other cats...
*
While at home
While Outdoors
While in being boarded at a kennel
While being bathed/professionally groomed
I don't have cats
What diet brand/ flavor does your pet eat? How much daily? Please include any table food or treats they routinely get.
*
Do you have set feeding times?
*
Once a day
Twice a day
Three Times a day
Free Feed throughout day
How would you describe your pet's breath?
*
Not bad
Unpleasant
Really Bad (Needs mouthwash!)
Do you use dental care at home?
*
Yes
No
If yes, which type of dental care do you use?
Brushing teeth
Dental diet
Dental treats
Dental toys
What heartworm/ flea prevention is your pet currently taking? (Please choose all that apply)_
*
Trifexis
Revolution plus for cats
Sentinel
Heartgard
Nexgard
Bravecto
NONE
Other
Do you need a refill of heartworm / flea / tick prevention?
*
Yes
No
Please list all other medications or supplements that your pet is currently taking including dosages if possible.
*
Is your pet scratching or chewing?
*
Yes
No
If yes, please provide details.
Describe how often your pet vomits?
*
Frequently
Once in a while
Hardly Ever
If frequent, please provide details.
Which best describes your pet's water consumption?
*
Same as last year
More than last year
If more than last year, please provide details.
Is your pet having any urinating issues?(frequent urination, leaking or dribbling urine, having accidents, peeing outside litter box, marking)
*
Yes
No
If yes, please provide details.
Any history of allergies?
*
Yes
No
If yes, please provide details.
Any unusual lumps or growths?
*
Yes
No
If yes, please provide where they are located and how long they have been there.
Have you noticed any stiffness or lameness?
*
Yes
No
If yes, please provide details.
Any coughing or sneezing?
*
Yes
No
If yes, please provide details.
Is there anything else you would like us to know?
*
Submit
Should be Empty: