Full Exam History Questionnaire

Medical History Exam Questionnaire

Your pet has been scheduled for an examination with a veterinarian. Please bring a fresh stool sample from your pet to their appointment if your pet is having any gastointestinal symptoms like bowel movement irregularities or vomiting.

**Please fill out this form to the best of your ability prior to your appointment**

Clients Name:*

First NameLast Name

Pets Name:*

First NameLast Name

Phone Number*

Area CodePhone Number

Pets Name *

Name

Phone Number*

Area CodePhone Number

Please compete this form to the best of your ability

Your pet has been scheduled for an examination with a veterinarian. Please fill out this form completely to the best of your ability prior to your appointment. Please bring a fresh stool sample from your pet to their appointment if your pet is having any gastointestinal symptoms like bowel movement irregularities or vomiting.

Please enter Diet and Feeding information.*

Check the conditions that apply to your pet.*

Has your pet experienced this condition in the past?

How long has this condition(s) been going on for and with what frequency?

Check the symptoms that your pet is currently experiencing:*

Has your pet experienced this symptom in the past?

How long has this symptom been going on for and with what frequency?

Is your pet a dog, cat or other?*

DogCatOther

Think about your dog's activity in the past week. Check all the signs you've observed in your dog. (Please refer to the image below as reference)*

Do you think your dog shows signs of pain?*

YesNo

Have you noticed any changes in your dog's behavior?*

YesNo

Is your dog... Energetic & Enthusiastic*

	1	2	3	4	5	6

1 is My dog couldn't be less, 6 is My dog couldn't be more

Is your dog... Happy & Content*

	1	2	3	4	5	6

1 is My dog couldn't be less, 6 is My dog couldn't be more

Is your dog... Active & Comfortable*

	1	2	3	4	5	6

1 is My dog couldn't be less, 6 is My dog couldn't be more

Is your dog... Calm & Relaxed*

	1	2	3	4	5	6

1 is My dog couldn't be less, 6 is My dog couldn't be more

Has your pet ever been injured?*

YesNo

Have you ever given your dog medication for pain, such as aspirin?*

YesNo

Has your dog gained weight in the past year?*

YesNo

Think about your cat's activity in the past week. Check all the signs you've observed in your cat. (Please refer to the image below as reference)*

Climbing up stairs: do they 'bunny - hop', with both back legs hopping at same time, and/or stops for a break.Climbing down stairs: Do they angle their body to the side, descending one stair at a time, and/or stops for a break.Chasing moving objects: Do they slow down or take breaks during play.Jumping up: Do they hesitate before jumping up, doesn't clear jumps in one leap, and/or uses their arms to pull their legs up.Jumping down: Do they hesitate before jumping down, make small jumps vs. one big one and/or reaches down towards the ground instead of leaping.Running: Do they move at a slower speed and alternate between jogging & walking, and/or back feet angled together.Thinner Frame: Do they have a thinner section near hips compared to their shoulders.None of the above

Is your cat... Energetic & Enthusiastic (Vitality)*

	1	2	3	4	5	6

1 is My cat couldn't be less, 6 is My cat couldn't be more

Is your cat... Active & Comfortable (Comfort)*

	1	2	3	4	5	6

1 is My cat couldn't be less, 6 is My cat couldn't be more

Is your cat... Happy & Content (Emotional well-being)*

	1	2	3	4	5	6

1 is My cat couldn't be less, 6 is My cat couldn't be more

Has your cat's personality and sociability changed?*

YesNo

Has your Cat's urination or defecation habits changed?*

YesNo

Is your cat hiding more or does your cat seem to be "slowing down"?*

YesNo

Do you need a refill on any of these medications today?

Are there any other issues/concerns that you'd like to discuss at your appointment?

***Please leave this comment section blank for the veterinary staff to add any additional notations that you might have before your pet's exam**

Please arrive to your appointment at your scheduled time. Due to our current scheduling restrictions, if you are not able to arrive on time, we may need to reschedule your appointment.

Thank you for taking the time to complete our form. The information you provide is valuable and enables us to provide the best care for your pet. If there is anything else you'd like to discuss or to be evaluated, please communicate it to a team member prior to your appointment or at the beginning of your pet's appointment.

We look forward to seeing you at your upcoming appointment

Warm regards,

Your veterinary team at the Aurora Animal Care Community

Medical History Exam Questionnaire

OA Checklist

Medication/Supplement(s)