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Wellness Visit Questionnaire
Date
*
Pet's Name
*
Owner's Name
*
Phone number
*
General Health:
Has your pet had any of the following?
Has your pet had any of the following?
Coughing
Has your pet had any of the following?
Sneezing
Has your pet had any of the following?
Vomiting
Has your pet had any of the following?
Diarrhea
Any changes in urination or bowel movements?
*
Any changes in urination or bowel movements?
Normal
Any changes in urination or bowel movements?
Straining
Any changes in urination or bowel movements?
Accidents
Any changes in urination or bowel movements?
Increased Frequency
Any changes in urination or bowel movements?
Blood
Any lumps, bumps, or new growths you’d like checked out?
*
Any lumps, bumps, or new growths you’d like checked out?
A
Yes
B
No
If yes, where?
Any change in drinking habits, appetite, weight, or behavior?
*
Any change in drinking habits, appetite, weight, or behavior?
A
Yes
B
No
If yes, please describe:
Preventatives
Is your pet currently on any heartworm prevention?
*
Is your pet currently on any heartworm prevention?
A
Yes
B
No
If yes, which brand?
Is your pet on flea/tick prevention?
*
Is your pet on flea/tick prevention?
A
Yes
B
No
If yes, which brand?
Lifestyle
Does your pet:
*
Does your pet:
A
Visit Groomer
B
Boarding/Daycare
C
Go to parks
D
None of these
Go swimming / Hunting?
*
Go swimming / Hunting?
A
Yes
B
No
Medications & Other Notes
Is your pet currently on any medication? Please List:
Does your pet have any long-term health issues or past diagnoses we should know about?
*
Does your pet have any long-term health issues or past diagnoses we should know about?
A
Yes
B
No
If yes, please explain:
Any major surgical procedures?
*
Any major surgical procedures?
A
Yes
B
No
If yes, what were they?
Submit