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 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
Pet's Name *
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
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? *
Should be Empty: