Buck Creek - Pre-Exam History

1

To better serve you and your pet at their exam, we ask that you fill out this Pre-Exam History form.

Please complete this form at least 1 day prior to your pet’s appointment.

If you are new to our practice or have not been to our office in several years, please fill out our New Client Form as well.

2

Appointment Date and Time

Date

Hour

Minutes

3

Pet Owner Name* This field is required.

First Name

Last Name

4

Owner & Pet Information* This field is required.

Contact #

Email

Pet’s name

Reason for appointment

Where does your pet spend the majority of their time?

5

Any changes in eating or drinking?* This field is required.

Yes

No

6

If yes, please explain

7

What do you feed your pet? How much? How often?

8

Any vomiting or diarrhea?* This field is required.

Yes

No

9

If yes, please explain (when it started, frequency, color, etc)

10

Any changes in your pet’s urination? (amount, color, frequency, etc.)* This field is required.

Yes

No

11

If yes, please explain

12

Have you noticed any coughing, sneezing, or eye discharge?* This field is required.

Yes

No

13

If yes, please explain (when it started, frequency, color, etc)

14

Is your pet scratching or shaking their head?* This field is required.

Yes

No

15

If yes, please explain (when it started, any open sores, any odor, scale of 1 (not) to 10 (going crazy) how itchy is your pet)

16

Have you noticed your pet having any lameness, stiffness, trouble going up or down stairs, or problems laying down/standing back up?* This field is required.

Yes

No

17

If yes, please explain (when it started, worse at a certain time, etc)

18

Is your pet currently taking any medication, either OTC or prescribed?* This field is required.

Yes

No

19

If yes, please explain what the medication(s) is and how often your pet receives it

20

Do you need any of the following products while here for your appointment today?

Flea/tick prevention

Heartworm prevention

Medication Refill

21

If you need a medication refill, what product(s) do you need?

22

Is there anything else you would like to tell us about your pet?