Pre-visit Questionnaire for Sick patient Visits
Client Name:
Pets Name:
Breed:
Type of Pet:
Cat Dog
DOB/Approximate age:
Date/Time of appointment:
1. What is the main reason for your pet's visit?
2. What questions, if any do you have for the doctor?
3. Is your pet currently on a wellness plan?
No. Yes
4. Have you downloaded our app and are a member of our loyalty rewards program?
No. Yes
5. What is your pet's current diet (food, treats, etc)?
-How much do you normally feed your pet?
6. Have your pet's eating habits changed?
No, they are eating normally.
Yes. Please explain:
7. Have your pet's drinking habits changed?
No
Yes. Please explain:
8. Is your pet currently taking any medications?
No Yes
If yes please provide a list of medications, supplements, vitamins, herbal products or preventions your pet is currently taking.
9. Have your pet's bathroom habits changed?
No
Yes. Please explain (having accidents in the house, urinating outside the litter box, diarrhea, constipation, etc):
10. Is your pet vomiting?
No
If yes, How often? Daily Several times a week Weekly Monthly Almost never
11. Is your pet experiencing any coughing or sneezing?
No
Yes. Please explain:
12. Does your pet have any known allergies or has your pet ever had any reactions to injections or vaccines?
No
Yes. Please explain:
13. Does your pet go to a groomer, boarding facility, dog park, dog/cat shows, day care, or travel with you?
No
Yes. Please explain:
14. Have you noticed any change in their activity level or ability to move around?
No
Yes. What other pets do you have?:
15. Is your pet showing signs of pain?
No
Yes. Please explain:
16. Have you noticed any changes in your pets personality? (disorientation, vocalization, signs of aggression, etc) or sleep habits? (sleeping more that normally, pacing or restlessness at night, etc)
No
Yes. Please explain:
A treatment plan with an estimate of costs associated with your pet's care will be provided at time of services.
I have read and understand the statement above.