Pre-visit Questionnaire
SICK PET VISIT HISTORY FORM- This form allows you to share details about your pet’s symptoms to help our medical team understand your pet’s current condition and plan a gentle, stress-aware approach to care, in line with our Fear Free and AAHA standards. Please be as detailed as possible.
Name
*
First Name
Last Name
Pet's Name
*
Type of Pet
*
Dog
Cat
Other
Breed
*
How Old is your pet?
*
Less than 1 year of age
1 year - 6 years
7 years or older
I'm not sure how old my pet is
Please enter Diet and Feeding information.
*
Is your pet eating and drinking normally?
*
Yes
No
Please describe how your pet’s eating or drinking has changed, and when you first notices them.
How often does your pet go outside?
How often does your pet go to a groomer, dog parks, dog shows, day care and/or a boarding facility?
Is your pet currently taking any medications?
*
Yes
No
Please list all medications/vitamins/supplements/preventatives that your pet is currently taking.
Do you need a refill on any of your pets medications?
Yes
No
Which medication do you need refilled?
Does your pet have any known allergies or has your pet ever had any reactions to injections or vaccines?
*
Yes
No
Not sure
Please describe your pets allergies or any reactions they have experienced.
What is the primary reason for your visit. (you may choose more than one)
*
Check skin, itchy, rash,
Check lumps, mass
Vomiting
Trauma, open wound, bleeding
Check ears, possible ear infection
Allergies
Coughing/Sneezing
Anal glands
Diarrhea or Constipation
Check Eyes
Problems urinating or inapproriate urination behavior?
Weight-loss
Other
What symptoms or concerns have you observed? When did they first appear? Have they gotten worse, better?
*
What have you tried already? (medications diet, changes, etc) Did you notice a change because of those efforts?
*
Any recent changes to your pets environment? (New food, home changes, travel, exposure to toxins, etc.)
*
Have you noticed a change to your pets behavior? (stress, anxiety, lethargy, hiding, aggression, etc)
*
What other questions or concerns, if any, do you have for the doctor?
Client Acknowledgements:
*
I understand that I may request a written treatment plan and cost estimate for my pet’s care at any time, or one may be provided at the time of service.
Submit
Should be Empty: