Pre-Visit Questionnaire

Help Us Prepare for Your Pet's Visit
Thank you for completing this short form before your visit.

Your answers help our medical team prepare and focus on what matters most to you and your pet.
1. Patient name*
2. Client name*

First NameLast Name
3. Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
4. Email*
example@example.com
5. Appointment Date*

MonthDayYear
Date
6. What type of visit is this?*

WellnessSickRecheck/Medical progress
7. How is your pet doing overall?*

Doing great, no concernsMostly well with minor concernsI have specific concerns to discuss
8. Please check any that apply recently:*

VomitingDiarrheaDecreased appetiteIncreased thirst or urinationCoughing or sneezingItching or skin problemsLumps or bumpsBehavior or activity changesNone of the above
9. Is your pet currently on heartworm prevention?*

YesNoNot sure
9a. Which brand?
10. Is your pet currently on flea/tick prevention?*

YesNoNot sure
10a. Which brand?
11. Has your pet ever had a reaction to a vaccine?*

NoYes
11a. Which vaccine and describe the symptoms of the vaccine reaction.
12. What food does your pet eat? (brand/type)*
13. Is your pet currently on any medications or supplements?*

NoYes
13a. List any medications with dosages and supplements that your pet is currently on.
14. Do you need refills on any medication or prevention at your visit?*

YesNo
15. Lifestyle*

Indoor & outdoorIndoor onlyOutdoor only
16. Do you have pet insurance?*

YesNo
17. What questions or concerns would you like to be sure we address at your visit?
18. Would you like to include routine annual wellness bloodwork as part of your visit? This can help to detect issues early.*

YesNoI'd like more information before deciding
7. What is the main issue you'd like addressed at the visit?*
8. When did this problem start?*

Today1-3 days ago4-7 days agoMore than 1 week agoMore than 1 month ago
9. Is the problem:*

Getting betterGetting worseAbout the same
10. Please check any symptoms your pet is experiencing:*

VomitingDiarrheaReduced appetiteLethargyLimping or painCoughing or sneezingTrouble breathingIncreased drinking or urinationWeight lossEar issuesEye issuesSkin problemsOther
10a. Other symptoms:
11. Has this issue occurred before?

YesNo, this is a new issue
12. Any recent changes or events that could have caused this? (new foods, medications, environment, travel, new pets)*
13. What food does your pet eat? (brand/type)
14. Is your pet currently on any medications or supplements?*

NoYes
14a. List all medications with dosages and supplements:
15. Is your pet current on heartworm prevention?*

YesNoNot sure
15a. Which One?
16. Is your pet current on flea and tick prevention?*

YesNoNot sure
16a. Which one?
17. Do you have pet insurance?*

YesNo
18. How concerned are you about this issue is on a scale of 1-10 (10 being the worst)?*
19. Is there anything else you'd like the doctor to know?
7. What condition or problem are we rechecking at this visit?*
8. Overall progress*

Much improvedSomewhat improvedAbout the sameWorse
9. Which symptoms is your pet currently experiencing?*

No current symptomsVomitingDiarrheaDecreased appetiteIncreased thirst or urinationLethargyPain or limpingCoughing or sneezingSkin or ear issuesOther
9a. Other symptoms:
10. What food does your pet eat? (brand/type)
11. Is your pet currently on any medications or supplements?*

YesNo
11a. List all medications with dosages and supplements:
12. Is there any other information you would like the doctor to know?
Should be Empty:

Help Us Prepare for Your Pet's Visit

Thank you for completing this short form before your visit.