Town & Country Animal Hospital Pet Examination Questionnaire

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 NameLast Name
Spouse's name or partner's name to be added to your account

First NameLast Name
Email to link to your pet's medical record.*
example@example.com
Phone Number*

Area CodePhone Number
Spouse or partner's phone number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet's Name*
Is this our first time seeing your pet?*

YesNo
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?*

YesNo
For dog owners- Does your Dog come in contact with other dogs....*

While at homeWhile boarded at a kennel facilityWhile professionally groomedWhile bathedWhile at a dog parkWhile at dog showsI don't have dogs
For Cats only- My cat spends most of the time...*

Indoors onlyOutdoorsIndoors & Outdoors equallyI don't have cats
For Cats only- My cat comes in contact with other cats...*

While at homeWhile OutdoorsWhile in being boarded at a kennelWhile being bathed/professionally groomedI 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 dayTwice a dayThree Times a dayFree Feed throughout day
How would you describe your pet's breath?*

Not badUnpleasantReally Bad (Needs mouthwash!)
Do you use dental care at home?*

YesNo
If yes, which type of dental care do you use?

Brushing teethDental dietDental treatsDental toys
What heartworm/ flea prevention is your pet currently taking? (Please choose all that apply)_*

TrifexisRevolution plus for catsSentinelHeartgardNexgardBravectoNONEOther
Do you need a refill of heartworm / flea / tick prevention?*

YesNo
Please list all other medications or supplements that your pet is currently taking including dosages if possible.*
Is your pet scratching or chewing?*

YesNo
If yes, please provide details.
Describe how often your pet vomits?*

FrequentlyOnce in a whileHardly Ever
If frequent, please provide details.
Which best describes your pet's water consumption?*

Same as last yearMore 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)*

YesNo
If yes, please provide details.
Any history of allergies?*

YesNo
If yes, please provide details.
Any unusual lumps or growths?*

YesNo
If yes, please provide where they are located and how long they have been there.
Have you noticed any stiffness or lameness?*

YesNo
If yes, please provide details.
Any coughing or sneezing?*

YesNo
If yes, please provide details.
Is there anything else you would like us to know?*
Should be Empty: