Annual Exam Questionnaire

PATIENT HISTORY FORM

*If you are coming for boosters and have filled this form out recently you don't need to fill it out again. Thank you
Full Name*

First NameLast Name
Pets Name *
Phone Number*
Please enter Diet and Feeding information.*
What parasite risk factors is your dog* exposed to throughout the year?

Has been or plans to be boardedGoes to dogs parks or high traffic dog areasCatching or consuming wildlife, ability to scavenge off leash in wildlife populated areasExposure to areas with wildlife where they explore on or off leashWalk or play in parks, picnic areas, campgrounds, hiking areas
Does your cat* ever explore the outdoors?

No, would never leave the comforts of homeOccasional escape artists but regrets decision quicklyWill explore supervised in a secure areaBorn to wonder and spends a lot of time outside during their preferred season(s)Can barely convince them to come back inside
Check the conditions that apply to your pet.*

CoughingSneezingVomitingDiarrheaEye DischargeDirty/Itchy EarsNasal DischargeLimpingSkin IssueNew or changed lumpNo concernsOther
How long has this condition been going on for and with what frequency?
Has your pet experienced this condition in the past?
Check the symptoms that your pet is currently experiencing:*

Not eatingTrouble breathingTrouble DefecatingTrouble UrinatingWeight gainWeight lossChange in behaviorChange in activity level/mobilityNo concernsChanges in sleep habitsOther
How long has this symptom been going on for and with what frequency?
Has your pet experienced this symptom in the past?
Please list all medications/vitamins/supplements/preventatives that your pet is currently taking.
Has your pet ever had a reaction to vaccinations?*

YesNoNot Sure
Do you have tick concerns for your pet currently?

YesNoUnsure
Are there any other issues/concerns that you would like to discuss at your appointment?
What is your pets favourite toy/activity?
What is the nickname you use the most for your pet?
Should be Empty:

PATIENT HISTORY FORM