Patient Physical Exam Questionnaire

Hello,

Please provide the following information so we can expediate your pet(s) appointment. Please fill out each question even if it does not pertain to your visit today and be as descriptive as possible.

Your name *

First Name Last Name

Best contact phone number *

Area Code Phone Number

Are you currently experiencing any symptoms that could be related to the COVID-19 virus? We ask that if you are feeling ill that you do not bring your pet into the hospital and instead have a friend or family member bring your pet in. We are able to accommodate curbside service if you would like just please select that option below. *

I am not currently experiencing any symptoms I am currently experiencing symptoms I am not currently experiencing any symptoms but would like to use curbside services

Pets name *

What date is your appointment scheduled for? *

Date

Chief Complaint (Why is your pet being seen today?) *

Has your pet been coughing/gagging? *

Yes No

How long has it been going on? What kind of cough or gag is it? (Be descriptive)

Has your pet been sneezing? *

Yes No

How long has your pet been sneezing? Any discharge from nose? If so, describe. (Yellow, green, clear, blood, etc)

Has your pet had any recent vomiting? *

Yes No

How long has the vomiting been going on? What did it consist of? (Food, bile, something else?) How many times did they vomit and when was the last time?

Has your pet had any recent diarrhea? *

Yes No

How long has it been going on? Did you see blood or mucous? What is the consistency? Is your pet straining?

Has your pet had any constipation? *

Yes No

How long has it been going on? When was the last normal BM?

Has your pet had any trouble with urination? *

Yes No

How long has it been going on?

Select all that apply:

Straining Frequent Urination Blood in urine Mucous in urine Foul Smell

Is your pet drinking normally? *

Yes No

If no, how long has it been going on? Is your pet drinking more or less?

Is your pet eating normally? *

Yes No

If no, how long has it been going on? Is your pet eating more or less?

Nutrition (Brand, formula, wet/dry, how much? frequency. Any treats?) *

Does your pet get any human food/table scraps? If so, what kind and how often? *

Does your pet have any skin issues? (Licking/scratching/chewing on the skin or feet) *

Yes No

How long has it been going on?

On a scale of 1-10 how itchy is your pet? (1=Not much 10=scratching all the time)

What area(s) is affected?

Select all that apply in terms of your pets skin:

Lesions/Scabs Hair Loss Redness Fleas

Has your pet been scooting? *

Yes No

If yes, how long has it been going on? Do you see any blood? Does your pet seem to be in pain?

Have you noticed any new lumps/bumps on your pet? *

Yes No

If yes, when did you first notice it? Location? Has it gotten bigger/smaller than when you originally found it?

Is your pet having any issues with their eyes? *

Yes No

If yes, how long has it been going on? Which eye/both?

Select all that apply:

Eye discharge Eye redness Squinting

Is your pet having any issues with their ears? *

Yes No

If yes, how long has it been going on? Which ear(s) is/are affected?

Select all that apply:

Scratching at ears Shaking head Discharge from ears Painful ears

Does your pet have any issues with their mouth/teeth/gums? *

Yes No

If yes, how long has it been going on?

Select all that apply:

Bad breath Bleeding gums Missing/broken teeth

Does your pet have any trouble walking/running/jumping/getting up? *

Yes No

If yes, how long has it been going on? Is your pet limping? Which leg(s) is/are affected?

Has your pet been lethargic? *

Yes No

If yes, how long has it been going on?

Have you noticed any behavior problems with your pet? *

Yes No

If yes, please describe

Medications/Supplements (What kind? Dosage? Frequency?) *

Heartworm Prevention (Brand? Frequency? Last dose?) *

Flea/Tick Prevention (Brand? Frequency? Last dose?) *

Do you need refills of any kind while here? *

Do you need to purchase any food/products while here? *

COVID-19 POLICIES

* We are currently allowing clients into our hospital but for the safety of our staff and other clients, we ask that you continue to practice social distancing. Facial coverings are no longer required inside of our building but we encourage those who have not been fully vaccinated to continue to wear their mask.

* If you are feeling ill or experiencing signs of or have been diagnosed with COVID-19 we ask that you stay home and send someone else in with your pet.
* We continue to limit appointments to no more than two people in the exam room. If there are more people present, we will ask someone to wait outside during your visit.

We appreciate your cooperation. Thank you