Pre-appointment Information Questionnaire
We are asking these questions to ensure your account information is up-to-date and accurate as well as preparing us for your upcoming appointment. Only required fields have *. However, if you have more information to include, this will be helpful for us to determine your concerns and ensure nothing is missed in the process for providing medical care for your furry loved one/s.
Owner:
*
First Name
Last Name
Primary phone number we can reach you at:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
example@example.com
Has your address changed within the last 6 months?
*
Yes
No
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Appointment date:
*
-
Month
-
Day
Year
Date
Pet's name:
*
Species
*
Dog
Cat
Gender:
Intact/Non-altered female
Spayed female
Intact/Non-altered male
Neutered male
Unkown
Last heat cycle:
Does your pet have another veterinarian?
*
Yes
No
Contact information of any other veterinary hospitals your pet has been to:
Do you want to upload an image of your pet to display in their medical record?
Yes
No
Upload image:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Reason for your pet’s upcoming visit?
*
Technician/Nurse only visit (will not be seeing the Veterinarian – if your pet has medical concerns that need to be addressed, please contact our office to reschedule)
Wellness Veterinarian visit (NO medical concerns)
Veterinarian visit (Medical concerns)
Veterinarian visit, recheck exam
How are things?
*
My pet is doing great.
My pet is back to normal.
There has been some improvement.
There has been no improvement.
My pet's condition seems worse since last visit.
Health concerns for your pet (check all that apply)?
Respiratory
Ears
Eyes
Skin/Haircoat
Urinary Issues
Limping/Joint Issues
New/Changing Lump/Bump
Teeth/Mouth (ex: odor, trouble eating, drooling)
Anal Glands (ex: odor, scooting or licking bum)
Diarrhea
Vomiting
Weight Loss/Gain
Behavioral Issues
Not acting normal
Other
Please describe your pet’s medical concern(s) in more detail:
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Does your pet take any MEDICATIONS?
*
Yes
No
Please list all MEDICATIONS your pet is currently taking:
Does your pet take any SUPPLEMENTS (including joint supplements, skin and haircoat supplements, vitamins, holistic products, etc.)?
*
Yes
No
Please list all SUPPLEMENTS your pet is currently taking:
Is your pet on flea, tick, heartworm prevention?
*
Yes, both heartworm and flea/tick prevention.
Only heartworm prevention.
Only flea/tick prevention.
No, none.
What flea, tick, heartworm prevention is your pet on:
*
When was the last dose given/applied:
Does your pet need any refills of medications, supplements, or preventatives today?
Yes
No
Please list what is needed and quantity requesting:
Are you interested in home delivery for your pet's prescriptions?
Yes, please!
Maybe, can someone talk to me more about this option?
No, thank you.
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Your dog’s lifestyle (choose all that apply)?
*
Dog Parks
Daycare
Boarding
Grooming
Hiking
Hunting
Working dog
Dog shows
Never leaves home/yard except to go to the vet
Goes on leash walks around our neighborhood
Strictly indoors (never goes outside to potty, strictly uses potty pads or litter box indoors)
Other
Your cat's lifestyle (choose all that apply)?
*
Strictly indoors (never leaves the house except to go to the vet)
Catio or screened-in porch access
Supervised on-leash outdoors
Supervised off-leash outdoors
Indoor/Outdoor as pleases
Adventure cat (comes hiking/traveling)
Other
Does your pet live/spend part of the year elsewhere or do they have travel history outside of Tucson?
*
Yes (Please include where pet resides or has been outside of Tucson, AZ, within the travel history field below)
No
Travel history (States and/or Countries your pet has traveled or lived previously)?
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Name of your pet’s diet?
*
How much do you feed and how often? Example: 1 cup twice daily.
What treats does your pet receive, including human foods?
Any changes in hunger/eating and/or thirst/drinking habits?
*
Yes
No
Please describe changes in hunger/eating and/or thirst/drinking:
Any changes in bathroom habits?
*
Yes
No
Please describe changes in urination/defecation:
Any sneezing, coughing, vomiting, or diarrhea? Choose all that apply.
*
No to all.
Yes, sneezing.
Yes, coughing.
Yes, vomiting.
Yes, diarrhea or softer stools than normal.
Any reactions to vaccines or medications that you know of?
*
Yes
No
Please describe any reactions and to what:
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Are you willing to answer some questions regarding your pet's behavior leading up to and during veterinary hospital visits?
Yes.
No, thank you.
Are there any situations that your pet has tried to avoid or shown dislike of in the past? Choose all that apply.
Entering the vet hospital
Unfamiliar people or animals
Being approached by veterinary staff
Getting on the scale to be weighed
Going into the exam room
Being put up on the exam table
Having a rectal temperature taken
The use of instruments such as the stethoscope (to listen to the heart and lungs) or otoscope (to look in the ears)
Nail trim
None of the above
Other
How would you describe your pet around other animals and people?
Excited, confident, outgoing
Calm, confident, and inquisitive
Quiet, watchful, and stays close
Nervous, hides or tries to steer clear
More vocal than normal (barks, whines), but stays very close
Becomes leash reactive (barks, growls, pulls, lunges on leash)
Becomes aggressive (will try to bite or attack if within reach)
Other
If you have more to add to your above choice/s, please describe in more detail:
Does your pet have any sensitive areas that s/he does not like to have touched by you or others?
Yes
No, not that I know of.
Please briefly list sensitive areas:
Has your pet ever been given any supplements or prescribed any medications to help manage his/her fear or anxiety associated with vet visits?
Yes
No
Please list supplements and/or medications used:
Submit
Should be Empty: