Patient History Questionnaire
Please completely fill out the Patient History Questionnaire form prior to your appointment.
Owner Name
*
First Name
Last Name
Owner Email
*
example@example.com
Pet's Name
*
Why is your pet coming to see us?
*
Wellness Visit
Illness Visit
What is your pet eating? (Please select all that apply)
*
Dry Food
Wet Food
Treats
What brand of food do you feed your pet?
*
How often do you feed your pet?
*
What amount of food does your pet eat at each feeding?
*
How often does your pet eat human food?
*
What kind of food or treats other than pet food/treats are given to your pet?
*
How often do you brush your pet's teeth?
*
Daily
Sometimes
Not at all
Has your pet been eating normally?
*
Yes
No
How is your pet's water consumption?
*
Normal
Increased
Decreased
Is your pet on heartworm preventative?
*
Yes
No
If yes, what brand of heartworm prevention does your pet take?
How often do you give your pet heartworm prevention?
*
Every month, year round
Only during warmer months
Inconsistently
Is your pet on flea/tick preventatives?
*
Yes
No
If yes, what brand of flea/tick prevention is your pet on?
How often do you give your pet flea/tick prevention?
*
Every month, year round
Only during warmer months
Inconsistently
Is your pet on any other medications?
*
Yes
No
Is your pet on any supplements?
*
Yes
No
Do you need any refills of the above today?
*
Yes
No
If yes, which?
Has your pet had any of the following:
*
Coughing
Sneezing
Diarrhea
Vomiting
Changes in behavior
Limping or trouble with stairs
Bad breath or trouble chewing/eating
Change of appetite
None of the above
Does your pet have any lumps or bumps you would like looked at?
*
Yes
No
Has your pet had any issues with their skin?
*
Yes
No
Has your pet had any ear issues?
*
Yes
No
How many minutes of exercise is your pet getting a day?
*
None
15-30 minutes
30-60 minutes
More than 60 minutes
How is your pet's energy level?
*
Poor
Normal energy
Extra energy
Does your pet go outside?
*
Yes
No
Do you board your pet?
*
Yes
No
Do you take your pet to a groomer?
*
Yes
No
Do you take your pet to a daycare facility?
*
Yes
No
Any travel history outside of New England?
*
Yes
No
Does your pet see any other veterinarians or animal care specialists?
*
Yes
No
Do you have insurance for your pet?
*
Yes
No
Do you have any other questions or concerns that you would like to discuss at your pet’s appointment?
Have you had any contact with people known or suspected to have COVID-19 in the prior 14 days?
*
Yes
No
Submit
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