Cardiff Animal Hospital & Wellness Center
PATIENT CONSULTATION QUESTIONNAIRE
Pet's name
*
Client's name
*
First Name
Last Name
Email
*
example@example.com
Primary Number
*
-
Area Code
Phone Number
Is this a cell phone?
*
Yes
No
Why is your pet being seen today?
*
i.e., vomiting, diarrhea, lethargy, scratching ears, etc.
How long as the problem been going on?
*
Are you aware of anything that may have caused the symptoms?
Yes
No
If yes, please describe
*
i.e., my pet got into the trash, my pet fell while getting out of the car, etc.
Is your pet's ACTIVITY
*
Normal
Increased
Decreased
Is your pet's APPETITE
*
Normal
Increased
Decreased
Is your pet's THIRST
*
Normal
Increased
Decreased
Is your pet COUGHING?
*
Yes
No
If yes,
*
Clear
Productive
Is your pet SNEEZING?
*
Yes
No
If yes,
*
Clear
Mucoid
Is your pet VOMITING?
*
Yes
No
If yes,
*
Food
Bile
If yes, duration and frequency of vomiting
*
Does your pet have DIARRHEA?
*
Yes
No
If yes,
*
Soft
Liquid
Bloody
Mucoid
If yes, duration and frequency of diarrhea
*
Is your pet's mobility
*
Normal
Abnormal
If abnormal, please describe
*
Does your pet have any NEW MASSES or SKIN LESIONS?
*
Yes
No
If yes, please describe location and when first noticed
*
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Next
General Wellness
DIET & TREATS
What do you feed your pet?
*
Please provide name brand and formula of diet fed
Is this diet grain-free?
*
Yes
No
I don't know
Is this a raw diet?
*
Yes
No
I don't know
What volume of food do you offer your pet PER DAY?
*
How often is your pet fed?
*
Free feed
Once per day
Twice per day
Does your pet get treats or table-scraps?
*
Yes
No
If yes, what kind and how often?
*
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General Wellness
DENTAL CARE
Do you brush your pet's teeth?
*
Yes
No
If yes, how often?
*
Do you give your pet dental treats?
*
Yes
No
If yes, what kind and how often?
*
When was you pet's last dental cleaning?
*
Were dental x-rays performed?
*
Yes
No
Don't know
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Next
General Wellness
MEDICATIONS & CURRENT TREATMENTS
Is your pet on any current medications?
*
Yes
No
If yes, please list all medications, dosage and frequency of administration
*
Do you give your pet any supplements (i.e., glucosamine, omega fatty acids, probiotics, etc.)
*
Yes
No
If yes, please list the type and brand of all supplements and frequency of administration
*
Is your pet on a Heartworm preventative?
*
Yes
No
Unsure
If yes, please provide the name brand
*
Is your pet on a flea or flea and tick preventative?
*
Yes
No
Unsure
If yes, please provide the name brand
*
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Next
General Wellness
How often is your pet bathed or groomed?
*
i.e., weekly, monthly, I don't remember the last time, etc.
If your pet is a cat, what percent of time does your cat spend outdoors?
*
None, my cat is indoors exclusively
Less than 25% of the time outdoor
About 50% of the time outdoors
More than 75% of the time outdoors
N/A - my pet is a dog
Has your pet traveled outside the area in the past 12-months?
*
Yes
No
If yes, please describe where and for what duration
*
Do you plan for your pet to travel outside the area in the upcoming 6-months?
*
Yes
No
If you, please describe where and for what duration
*
Does your pet have pet insurance?
*
Yes
No
If yes, please provide the name of the pet insurance company, and policy number, if available
*
If you are interested, the Cardiff Animal Hospital will submit claims on your behalf. Please provide us with a blank claim form with your pet's information pre-printed on it, and we will fax it in after each visit.
Are there other pets in the household?
*
Yes
No
If yes, please provide their names, species, and breed information
*
Does your pet have a microchip?
*
Yes (If yes, we will scan it at the time of each exam to ensure it is still working)
No (If no, did you know the the new microchips can also provide us with your pet's body temperature at time of their visit (so no more rectal temperature checks)!
Is there any additional information about your pet's health that you would like to share with us?
Submit
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