Pre-Visit Questionnaire for wellness visits

Client Name:

Pets Name:


Type of Pet:

 Cat  Dog

DOB/Approximate Age:

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. Is your pet eating and drinking normally?

 Yes, they are eating and drinking normally,

 No, Please explain and provide date of when this started. 

6. What is your pet's current diet (food, treats, etc)?

   -How much do you normally feed your pet? 

7. 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.

8. Are interested in updated your pet's vaccines?


 Yes. Which vaccines? 

9.Have you noticed any of the following?

 None - My pet is healthy. (to the best of my knowledge.

 Yes. See Below:

        Coughing / Sneezing / Nasal Discharge

        Vomiting / Diarrhea

        Lameness / Pain / Difficulty Standing, playing, and or jumping.

        Skin / Ear irritation

        Lumps / Bumps

        Urine Issues

        Appetite / Weight Changes

        Behavioral Changes (Lethargy, restlessness)

        Trauma / Body Injury



10. Does your pet have any known allergies or has your pet ever had any reactions to injections or vaccines?


 Yes. Please explain:

11. Does your pet go to a groomer, boarding facility, dog park, dog/cat shows, day care, or travel with you?


 Yes. Please explain:

12. Do you have other pets at home?


 Yes. What other pets?:

13. Please describe your pet's dental care regimen such as brushing (type of paste and frequency), food or water additive type and frequency, oral diet type and frequency, dental treats (brand, quantity, and frequency): 


14. FOR CANINE PATIENTS: Are you interested in updating your pet's annual heartworm test if due?

 Yes. Please screen my dog for HW and tick-borne diseases.

 No. I am not interested at this time.

15. FOR FELINE PATIENTS: If your cat travels or spends time out of doors, we recommend they be screened for FELV (Feline Leukemia) and FIV annually. Are you interested in updating your pets annual FELV/FIV test? 

 Yes. Please screen my cat for FELV and FIV.

 No. My cat only goes outside for their annual wellness exam. 

 No. My cat does go outside, but I am not interested in screening them at this time. 

16. FOR SENIOR PETS: Because a pet’s health can change with age, pets over the age of 7 are considered Seniors and routine bloodwork is recommended to screen for conditions more prevalent with older pets like: Diabetes, Liver Disease, Kidney Disease and Thyroid Disease just to name a few. 

 Yes, I am interested in bloodwork for my pet.

 No, I am not interested at this time.

 My pet has already had blood work done on:

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. 

Because of possible zoonotic risks, the CDC recommends that every pet be checked annually for internal parasites. Therefore, we ask that you please bring a fresh fecal sample with you to your pet’s visit. Samples will be submitted to a lab for analysis and the results will be available within 48 hours of your visit. 

 I have read and understand the statement above.


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Our Hours

8:00am - 7:00pm
8:00am - 6:00pm
8:00am - 6:00pm
8:00am - 7:00pm
8:00am - 6:00pm

Our Funkstown veterinarians offer a wide variety of pet care services including spay and neutering, general exams, vaccinations, and much more. Contact Animal Health Clinic of Funkstown today to schedule an appointment at our Funkstown, Maryland veterinary office.

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