Patient Physical Exam Questionnaire

Patient Physical Exam Questionnaire
Hello,

Please provide the following information for your pets upcoming day admission 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
Pets name*
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:

StrainingFrequent UrinationBlood in urineMucous in urineFoul Smell
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?*
Please verify that you are human*
COVID-19 POLICIES

* We are currently curbside, but for the safety of our staff and other clients, we ask that you practice social distancing and wear a mask during the duration of your visit with us.

* 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 with your pet.

We appreciate your cooperation. Thank you!
Should be Empty:

Now create your own Jotform - It's free!Create your own Jotform