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 NameLast Name

Best contact phone number*

Area CodePhone Number

Best Email to have on file:

example@example.com

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?*

YesNo

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

Has your pet been sneezing?*

YesNo

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?*

YesNo

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?*

YesNo

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?*

YesNo

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

Has your pet had any trouble with urination?*

YesNo

How long has it been going on?

Select all that apply:

Is your pet drinking normally?*

YesNo

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

Is your pet eating normally?*

YesNo

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)*

YesNo

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/ScabsHair LossRednessFleas

Has your pet been scooting?*

YesNo

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?*

YesNo

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?*

YesNo

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

Select all that apply:

Eye dischargeEye rednessSquinting

Is your pet having any issues with their ears?*

YesNo

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

Select all that apply:

Scratching at earsShaking headDischarge from earsPainful ears

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

YesNo

If yes, how long has it been going on?

Select all that apply:

Bad breathBleeding gumsMissing/broken teeth

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

YesNo

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

Has your pet been lethargic?*

YesNo

If yes, how long has it been going on?

Have you noticed any behavior problems with your pet?*

YesNo

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?*

Our PAW Plans help manage your pet's preventive care and mitigates unexpected costs throughout all life stages.

If you'd like to read about the wellness plans we offer, please visit this link:

Paw Plan Information