Town & Country Animal Hospital New Pet Examination Questionnaire

Town & Country Animal Hospital New Pet Examination Questionnaire
Name *

First Name Last Name
Pet's Name *
Email
example@example.com
Phone Number *

Area Code Phone Number
Reason for your visit? *
What diet brand/ flavor does your pet eat? How much daily? *
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
Do you need a refill of heartworm / flea / tick prevention? *

Yes No
Please list all other medications that your pet is currently taking including dosages if possible. *
Is your pet scratching or chewing? *

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.
Which best describes your pet's water consumption? *

Same as last year More than last year
Is your pet eating or drinking normally? *

Yes No
If no, please provide details.
Have you noticed any stiffness or lameness? *

Yes No
If yes, please provide details.
Any vomiting or diarrhea? *

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? *
Should be Empty: