Medical Follow-Up Questionnaire

We hope that your pet is feeling better. To better understand & provide the ultimate care for your companion, please carefully review through the following information questionnaire for your appointment.

Pet's NameLast Name

Date of Appointment*

Date

Time of Appointment*

:HourMinutesAM/PM Option

Date of primary visit.*

Date

What were the initial problem(s) that your pet was seen for?*

Is the problem(s); the same, better or worse?*

If worse, please briefly explain.

Has your pet developed any of the following issues since their last visit; coughing, sneezing, vomiting or diarrhea?*

If yes, please briefly explain.

Describe your pet's activity level;*

SedentaryLightly ActiveActiveVery Active

Does your pet have any known vaccine or medication reactions?*

If yes, please briefly explain.

Has your pet had any change in their water consumption?*

If yes, please briefly explain.

What is your pet's current diet & feeding schedule is?*

Food Name/Type & How Much/How Often- specify if food is grain-free

Is your pet currently on any medications or supplements; including heartworm & flea/tick medication?*

If yes, please list type and last date given.

Do you have any additional questions or concerns for the Dr. as pertains to the initial problem?*

If yes, please briefly explain.

APPOINTMENT REMINDER

This appointment is to address the initial issue/problem that your pet was seen for. Unfortunately, we are not able to address additional or seperate concerns for your pet during this visit. If your pet is experiencing new or worsening symptoms or you have additional concerns, please call our office at 757-483-3800 to notify our team, as we may need to adjust your appointment.

Failure to notify our team of additional concerns or worsening symptoms may result in having to schedule a seperate appointment to have those concerns addressed.

Medical Exam : Follow-Up