Form
Pre- appointment questions for Glenway Animal Hospital
Date and time of appointment:
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Current Address
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Preferred phone number: include cell phone provider if you want to receive text messages
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Email address
Client and pet name (provide alternative name if two different owner names):
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Do you have any concerns today?
Does your pet have a Microchip?
Is your pet currently taking medications? If yes please list all medication, dosing, and frequency.
Any adverse reaction to any medications or vaccinations?
What are you currently feeding your dog? (Brand, wet vs dry, and amount)
Does your dog spend time outside? If yes how much?
Do you use a monthly antiparasitic medication? If yes please specify (ex: Simparica Trio, Interceptor, Sentinel, Trifexis, Nexgard)
Does your dog interact with other dogs, not from your household? Going to doggy day care, pet store, kennel, groomer, pet store or groomer? Yes or no (where)
Does your pet spend time in rural areas, camping or hiking? Yes or No
Do you do any home dental care? If so specify
Do you live less than 2 miles from any open water, such as ponds, creeks or flood zone? Yes or no
Do you have wildlife in your yard or see wildlife, such as raccoons, opossums or rodents in the areas surrounding your house? Yes or no
Does your pet travel out of the state of Ohio? If so, where?
Do you know a person or dog that tested positive for Lyme disease? yes or no
Does your pet have a history of chronic illness? If so, please specify, Heart Disease, Dental Disease, etc.
Does your pet have pet insurance? If yes, please specify the company?
Does your dog have trouble jumping or going up stairs?
Does your dog lag behind on walks or limp after exercise?
Is your dog slow to rise or does your dog seem stiff?
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