Wellness Appointment Questionnaire

Wellness Appointment Questionnaire
Client Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com
Pet Name *
Appointment Date

Month Day Year
Date
Appointment Time

: Hour Minutes AM/PM Option
Species *

Dog Cat
Age *
Gender *

Male Female
Neutered or Spayed? *

Yes No
When was the last heat cycle?
Do you plan to neuter or spay your pet? *

Yes No
Do you plan to breed your pet? *

Yes No
Why do you plan to breed? *
Diet
What does your pet eat (brand and quantity)? *
What treats does your pet eat (brand and how often)? *
What human food does your pet eat? *
Medications and Preventatives
What heartworm preventative do you give your pet? *
What flea preventative do your give your pet? *
What medications is your pet currently taking? *
Does your pet take any supplements or non-prescription items? *
If you need refills on any of the above, please type which ones: *
Has your pet had any adverse reactions to vaccinations? *

Yes No
Please describe the reaction. *
Lifestyle
Please choose the option that fits best: My pet spends time... *

Indoors and outdoors (in a fenced back yard or walked on a leash) Indoors and outdoors (loose inthe woods or fields) Indoors and outdoors (but only on a porch) Indoors only, but sometimes the windows are open Indoors only, but other pets in the household go outdoors Indoors exclusively Outdoors exclusively
If your pet goes outdoors, what is its potential exposure to wildlife? *

High (rural area) Medium (large back yard, maybe a creek or woods nearby) Low (small, fenced, urban back yard)
Does your pet ever go to boarding, grooming, day care, or dog parks? *

Yes No
Does another pet in your household ever go to boarding, grooming, day care, or dog parks? *

Yes No
Do you use a pet sitter? *

Yes No
Do you show your pet? *

Yes No
Health Concerns
Has your pet been vomiting? *

Yes No
Has your pet been having diarrhea? *

Yes No
Has your pet been sneezing? *

Yes No
Has your pet been coughing? *

Yes No
Have you considered acupuncture for any chronic conditions? *

I'd like to know more about it Not interested at this time
Do you have any particular concerns or questions for us to address at your appointment?
Should be Empty:

Wellness Appointment Questionnaire

Diet

Medications and Preventatives

Lifestyle

Health Concerns