Patient Intake Questionnaire

Patient Intake Questionnaire
Pet Name*
Owner Name (First and Last)*
Phone Number*
Date of Appointment*

MonthDayYear
Appointment Time*
Veterinarian:*
Type of Visit: (required field)*

Medical concern or questionFollow-up appointment (discounted exam rate within 1 month of the original problem visit)Wellness examination, vaccinations and testing (annual for adults, biannual for seniors)
In just a few words, please describe your concern:*
Please provide more detail about your concern(s) if you would like. (How long has this been a problem, do you suspect you known the cause, have you tried treatments already)?
Are there other past diagnoses that you think might relate to this problem or that we need to notate in our records?
Please list medications including milligram or milliliter amounts and frequency if different than prescribed or if not prescribed by Indian Trail Animal Hospital: (ex: Vetmedin 1.25mg - 1/2 tablet once daily in the morning)
Is this a urinary concern?

Yes (please bring a urine sample in a clean, dry container with you to the visit if possible. It can be refrigerated for up to 24 hours. If you are unable to collect a urine sample at home, be sure your dog doesn't urinate on the way into the hospital)No
Is this a stool concern?

Yes (please bring a fecal sample in any container, marble sized is plenty)No
Do you have concern that this could be contagious?

Yes (please text or call us when you arrive before coming into the building)No
Do you give pre-visit pharmaceuticals to your pet before visiting the hospital to help with anxiety?

Yes (please check to be sure that you have un-expired medication to administer or contact our office if not)No
Are there any challenges to treatment we should be aware of (ex: pills are difficult, can't get pet to hospital without help, etc.)?
Anything else you would like to add?
Do you have any additional requests for this visit?

Nail trimAnal sac expressionEar cleaningWellness updatesRefill(s)*Other - please list below
*Other
Thank you for taking the time to share this information with us. We look forward to helping your pet.
Do you feel that the condition we were treating was...*

ResolvedMostly betterMildly improvedThe sameWorseI'm not sure
Please explain more about your answer above
Do you give pre-visit pharmaceuticals to your pet before visiting the hospital to help with anxiety?

Yes (please check to be sure that you have un-expired medication to administer or contact our office if not)No
Please list medications including milligram or milliliter amounts and frequency if different than prescribed or if not prescribed by Indian Trail Animal Hospital: (Ex: Vetmedin 1.25mg - 1/2 tablet once daily in the morning)
Do you need refills today?

YesNo
If yes, please list refills needed
Do you have any additional requests for this visit?

Nail trimAnal sac expressionEar cleaningWellness updatesRefill(s)*Other - please list below
*Other
Thank you for taking the time to share this information with us!
The wellness examination, vaccinations, and testing visit is a good time for us to review your pet's health and help you plan for your pet's future. Please complete the information below in as much detail as you can so you can get the most benefit out of your visit. We look forward to seeing you soon!
Please select if this is a Canine or Feline visit:*

CanineFeline
Core vaccinations: I want to keep my pet's core vaccinations up-to-date for their health and well-being following current medical guidelines

YesNoI have questions before answering (these will be addressed at the time of your visit)
Core tests: I want to keep my pet's core tests up-to-date following current medical guidelines

YesNoI have questions before answering (these will be addressed at the time of your visit)
Lifestyle vaccinations - Which lifestyle vaccinations would you like to protect your pet for?
Lyme disease (now endemic in North Carolina and transmitted by ticks often too small to see)

YesNoMore information needed at my appointment
Canine Flu (intermittent outbreaks of mild to severe respiratory disease

YesNoMore information needed at my appointment
Feline Leukemia vaccination (important if your pet goes outdoors or on a patio for ANY time; a negative test may be needed first)

YesNoMore information needed at my appointment
Feline Bordetella (for cats that are frequently around other cats including boarding)

YesNoMore information needed at my appointment
What canine prevention(s) do you use?

Interceptor Plus (our top recommendation for heartworm and intestinal parasite prevention in dogs)QuattroProHeart InjectionHeartgard PlusCredelio (our top monthly recommendation for flea and tick prevention in dogs)Bravecto - Chewable (our top quarterly recommendation for flea and tick prevention in dogs) OR 1 year Injectable (Bravecto Quantum)Vectra3DNone*Other - please list below
*Other
What feline prevention(s) do you use?

Revolution Plus (our top recommendation for heartworm, flea, tick, and intestinal parasite prevention in cats)None*Other - please list below
*Other
Please list medications including milligram or milliliter amounts and frequency if different than prescribed or if not prescribed by Indian Trail Animal Hospital: (Ex: Vetmedin 1.25mg - 1/2 tablet once daily in the morning)
Do you need refills today?

YesNo
If yes, please list refills needed
What is the name of food or foods that your pet eats?
What is the volume of food that your pet eats and how often (ex: 1/4 cup twice daily)
Are you in the process of making any changes to your pet's nutritional plan?

Yes, trying to get them to lose weightYes, trying to get them to gain weightNo
Would you like us to do an of the following for your pet today?

Nail trimClean earsAnal sac expressionSanitary trim under tail
Please check any of the following health concerns that you have noticed...

VomitingDiarrhea/soft stools*Scratching or licking*Lumps or bumps*Skin or coat changes*Limping/lamenessBad breathWeight lossWeight gainAppetite changeCoughingUrinary problemsSlower to use steps, jump or stand up/sit downScootingChanges in visionChanges in hearing**Other (please describe below)
*If checked, please indicate where
**Other
Do you give pre-visit pharmaceuticals to your pet before visiting the hospital to help with anxiety?

Yes (please check to be sure that you have un-expired medication to administer or contact our office if not)No
Are there any challenges to treatment we should be aware of (ex: pills are difficult, can't get pet to hospital without help, etc.)?
Anything else you would like to add?
Thank you for taking the time to share his information with us. We look forward to your visit!
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