Patient History Questionnaire Norwood

Patient History Questionnaire
Owner First and Last Name*

First NameLast Name
Pet's Name*
Why is your pet coming to see us?*

Cat Annual Wellness VisitDog Annual Wellness Visit
If you selected Cat Annual Wellness Visit, what services would you like your pet to receive while they're here?

Rabies VaccineFeline Distemper VaccineFecal AnalysisAnnual Wellness LabworkNail TrimOther
If you selected Dog Annual Wellness Visit, what services would you like your pet to receive while they're here?

Rabies VaccineCanine Distemper VaccineKennel Cough VaccineLyme VaccineFlue VaccineFecal AnalysisHeartworm TestAnnual Wellness LabworkNail TrimOther
If you selected Illness Visit, what is your pet's primary reason for coming in to see us?
What is your pet eating? Please select all that apply:*

Dry FoodWet FoodTreats/Snacks
Please list the brand, flavor, quantity, and frequency per day:*
Has your pet been eating normally?*

YesNo
If your pet has not been eating normally, what are your concerns with how he/she is eating?
Does your pet have chew toys?*

YesNo
If you answered yes, what types of toys are they?
How is your pet's water consumption?*

NormalIncreasedDecreased
Is your pet on a heartworm preventative?*

YesNo
If yes, what brand is it?
If yes, how often do you provide heartworm preventative?

Once per monthOnly in the Spring/SummerWhen I rememberOther
Is your pet on a flea/tick preventative?*

YesNo
If yes, what brand is it?
If yes, how often do you provide flea/tick preventative?

Once per monthOnly in the Spring/SummerWhen I rememberOther
Is your pet on any other medications?*

YesNo
If yes, please list medications and their dosages per day:
Is your pet on any supplements?*

YesNo
If yes, please list any supplements taken and their dosages per day:
Has your pet had any coughing?*

YesNo
If yes, please list when it started, and how often it is occurring:
Has your pet had any sneezing?*

YesNo
If yes, please list when it started, and how often it is occurring:
Has your pet had any diarrhea?*

YesNo
If yes, please list when it started, and how often it is occurring:
Describe the appearance (watery, mucous, bloody):
Has your pet had any vomiting?*

YesNo
If yes, please list when it started, and how often it is occurring:
Describe the appearance (color, contents):
How many minutes of exercise is your dog getting per day?*

None15-30 minutes30-60 minutesMore than 60 minutes
How is your pet's energy level?*

PoorNormalExtra energy
Does your pet go outside?*

YesNo
If your pet goes outside, does your pet go for walks?

Yes, on leashYes, off leashNo
Does your pet go anywhere for boarding?*

YesNo
Does your pet go anywhere for grooming or daycare?*

YesNo
Do you have any recent travel history outside of New England?*

YesNo
If yes, when, and to where?
Does your pet see any other veterinarians or animal care specialists?*

YesNo
If you selected yes, please list the name of the veterinarian or animal care specialist:
Do you have insurance for your pet?*

YesNo
If you selected yes, please list the company name:
Is there anything else you would like your veterinarian to be aware of?*

YesNo
If you selected yes, please describe:
As Fear Free Certified Professionals, we want to make your pet's veterinary experience as enjoyable and stress-free as possible. Are you interested in providing more information about your pet's behavior so we may accommodate their needs upon arrival?*

YesNo
Does your pet show any reluctance to getting in the carrier or car?*

YesNo
How and where does your pet travel in the car (carrier, seatbelt, loose, etc.)? *
During travel to the veterinary hospital, does your pet do any of the following:*

Eager & excitedBark/meowDroolTrembleSubduedHidePantUrine/BMReluctantWhineVomitPaceNone of the aboveOther
Does your pet prefer:*

Female veterinary professionalMale veterinary professionalDoesn't matter
Check any situations listed below that your pet has shown avoidance or dislike of in the past. You can add additional comments at the end.*

Getting in their carrier or the carEntering the veterinary hospitalOther pets and/or people passing by while in reception/check-inWaiting with other people and animals in the waiting areaBeing approached by veterinary staffGetting on the scale for a weightHearing the doorbell, overhead intercom, or phones ringingSounds coming from the back areas of the practiceGoing into the exam roomBeing put up on the table for examinationHaving direct eye contact with the technician and/or veterinarianLoud voices during examinationHaving a rectal temperature takenThe use of instruments such as the stethoscope or otoscope (to look in the ears)Being taken out of the exam room for proceduresNone of the above
How would you describe your pet around other animals and people? *
Does your pet have any sensitive areas that s/he does not like to have touched by you or others?*
Are there any procedures your pet has not liked having performed at the veterinary hospital in the past or that seemed difficult for you or the staff to do? (nail trims, weight, temperature, ear exam, blood draw) If so, how did your pet react?*
What are your pet’s favorite treats? (Please bring some to your next visit to our hospital) *
Does your pet like to play with toys? If so, what kinds? *
Has your pet ever been prescribed any supplements or medications to help with a visit to the veterinary hospital? If so, what was it and what sort of results did you experience? *
Anything else you would like us to know?
Should be Empty: