New Client Intake & Medical History Form

Pre-Visit Questionnaire Form
Client Name

First NameLast Name
Pet name
Has your pet ever been prescribed supplements or medications to help with visits to the vet? If so, what was it and what results did he/she have?
During travel to the vet, does your pet do any of the following?

ExcitedSubduedReluctantHideVocalizesWhineDroolPantVomitTremblePaceUrine/BM
Does your pet prefer:

Female VeterinarianMale VeterinarianNo preference
Check any situations/procedure that our pet has shown dislikes of or avoidances in the past:

Entering the hospitalWaiting in a busy reception areaBeing approached by strangers/staffOther pets/people passing bySlippery floors/surfacesGetting on the scale for weight checkBeing held during examSeparation anxiety from ownerBeing put on the table for examBlood drawsEar examinationNail trimsMouth examinationRectal temperature takenOther
If yes to any of the above, how did your pet react?
Does your pet have any allergies we should be aware of?
How would you describe your pet around other animals and people?
Has your pet ever become protective of you around other animals or people? If so, how did your pet react?
Does your pet have any senstive areas that they do not like to have pet or touched?
Where/how did you get your pet? How long have you had them for?
Do you know your pet's history before they came to you? if yes, please describe.
Should be Empty:

Pre-Visit Questionnaire Form