Pre-Visit Questionnaire
Client Name
*
First Name
Last Name
Email
*
example@example.com
Pet Name
*
Please list your concerns regarding your pet’s health and the reason(s) for your upcoming visit.
*
Have there been any changes and/or new concerns?
Yes
No
If yes, can you please give us more details.
If you are a new client, please provide the name(s) of your previous veterinary hospital(s) for us to contact to request records.
Please indicate changes and/or new concerns below:
Vomiting
Diarrhea
Coughing
Sneezing
Discharge (from nose, eyes, and/or genitals)?
Changes in urination or drinking habits?
Changes in energy or activity level
Changes in mobility (limping, lameness, and/or soreness)
Changes in behavior
Changes in appetite
Changes in weight/body condition
Itchiness (scratching, licking, head shaking, etc)
Any new lumps or bumps, or changes in existing ones
If vomiting, can you give us more details?
If diarrhea, can you give us more details?
If coughing, can you give us more details?
If sneezing, can you give us more details?
If discharge, can you give us more details?
If changes in urination or drinking habits, can you give us more details?
If changes in energy or activity level, can you give us more details?
If changes in mobility (limping, lameness, and/or soreness), can you give us more details?
If changes in behavior, can you give us more details?
If changes in appetite, can you give us more details?
If changes in body weight/condition, can you give us more details?
If itchiness, can you give us more details?
If any new lumps or bumps, or changes in existing ones, can you give us more details?
What medications (including supplements, flea/tick/heartworm preventives, vitamins, topical medications, CBD products) is your pet currently taking? Please include dose (i.e., 25mg or 1mL) and frequency (i.e., once daily, twice daily) of medications.
*
Submit
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