Pre-Exam Questionnaire I

Pre-Exam Questionnaire

To prepare for your pet’s upcoming appointment, we ask that you complete the following short Pre-Exam Questionnaire. It is helpful if you are able to reply with this information at least 24 hours prior to your appointment, thank you in advance!
Name*

First NameLast Name
Pet's Name*

First NameLast Name
Appointment Date & Time

MonthDayYear
Date
Hour MinutesAM/PM Option
Please ensure that you are available by phone at ALL times until your pet is released back into your care.
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Secondary Phone Number
Please enter a valid phone number.
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dietary Information
What brand of food is your pet currently eating?*
How much food and how often do you feed?*
What type of treats do you feed your pet?*
Symptoms or Problems
Has your pet had any recent vomiting, diarrhea, coughing, and/or sneezing?*
How long has this condition been going on for and with what frequency? *
Have there been any changes in eating/drinking?*
How long has this condition been going on for and with what frequency? *
Have there been any changes in urination?*
How long has this condition been going on for and with what frequency? *
Have there been any changes in bowel movements?*
How long has this condition been going on for and with what frequency? *
Any concerns about stiffness, soreness or pain?*
Are there any other symptoms your pet is having?*

SkinEarsToe NailsChange in BehaviorNo Other Concerns
Does your pet have any chronic health concerns?*

Kidney DiseaseHeart DiseaseHyperthyroidismAllergiesDiabetiesNone that I know of
Please list all medications/vitamins/supplements/preventatives that your pet is currently taking either prescribed or over-the-counter.
Are there any issues/concerns about giving your pet an oral or topical medication? (I.e. difficulty giving tablet vs. liquid oral medication)*
Please explain difficulty in giving medications.
Has your pet ever had a reaction to vaccinations?*
Is your pet on heartworm prevention and/or flea+tick prevention?*
Please list current preventions.
Do you need any of the following while you are here for your appointment? (Select all that apply)

Heartworm PreventionFlea/Tick PreventionVaccinesMedication RefilledIntestinal Parasite (Fecal) Lab TestHeartworm/Tick Parasitology (Blood) TestAnnual Full Organ Function Lab ScreeningUrinalysisMy pet doesn't need anything elseOther
Are there any other issues/concerns that you would like to discuss at your appointment?
Family Pets - Do you need any other medications refilled or food for any other household pets at your upcoming visit? Please list pet name and medication.
Please arrive to your appointment 5-10 minutes before 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.
Authorization: I authorize Lazy 5 Veterinary Hospital to do whatever is necessary should an emergency arise. Should my pet become ill or injure iteself, and L5V is unable to contact me at the numbers that I have provided, my pet will be treated as deemed necessary by the attending DVM at my own expense.
Signature*

Clear
EMAIL 2
example@example.com
Should be Empty:

Pre-Exam Questionnaire

Please ensure that you are available by phone at ALL times until your pet is released back into your care.