Medical Appointment Questionnaire

North Suffolk Animal Clinic

Medical Appointment Questionnaire
We are sorry that your pet is not feeling well. To better understand & provide the ultimate care for your companion, please carefully review through the following information questionnaire for your appointment.
*

Pet NameLast Name
Date/time of Appointment:*

MonthDayYear

Hour MinutesAM/PM Option
Briefly describe the reason for your pet's visit: *

0/99
When was the issue first noticed?*

MonthDayYear
Date
Since onset of issue(s), they have; *

NUTRITION:
What is your pet's regular diet? Is the food grain-free? Specify brand/type:*

0/50
How much and how often each day?:*

0/50
Do you give treats and/or human food? If so, what kind, how much and how often?:*

0/100

MEDICATIONS / SUPPLEMENTS:
Is your pet currently on preventative medications (i.e. heartworm/flea & tick)? If yes, please list medication name and last date given.*
Is your pet currently on any supplements? If yes, please list supplement name, dosing and last date given:*

0/100
Is your pet currently on medications other than preventative? If yes, please list medication name, dosing and last date given:*

0/100
Has your pet had any reactions to any vaccines and/or medications? If yes, please briefly explain below.*

MEDICAL HEALTH SCREENING:

These help us evaluate your pet's behavior and medical health
My pet;
is currently (select all that apply);*

sneezingcoughingvomitinghaving diarrheaNone of the above
has (select all that apply);*

itchy skinitchy earsitchy feetNone of the above
has had a change in attitude and/or behavior:*
is lethargic. If yes, please briefly explain symptoms.:*

0/100
has had a change in food/water consumption. If yes, please briefly explain:*

0/100
has had a change in old lumps, bumps or skin discoloration. If yes, briefly explain:*

0/100
has had a change in urination and/or bowel movements. If yes, briefly explain:*

0/100

RISK FACTORS:

These help us evaluate for exposure to environmental risks.
My pet is;*
My pet's activity level is; *
My pet goes to the groomer:*
My pet has been, goes to, or in the future will go to a boarding or daycare facility:*
My pet has the opportunity to drink or play in the water outside:*
My pet has contact with other animals, including wildlife, livestock and other pet's that don't live with me:*

Do you have any other questions or concerns for the doctor? If yes, briefly explain.
As a Reminder;

This appointment is to address the medical concerns that you are currently experiencing with your pet. If you are interested in vaccine updates or additional services, you will need to schedule a separate appointment for preventive care services.
Should be Empty:

North Suffolk Animal Clinic