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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?
Coughing
Sneezing
Vomiting
Diarrhea
Any changes in urination or bowel movements?
*
Normal
Straining
Accidents
Increased Frequency
Blood
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?
*
A
Yes
B
No
If yes, please describe:
Preventatives
Is your pet currently on any heartworm prevention?
*
A
Yes
B
No
If yes, which brand?
Is your pet on flea/tick prevention?
*
A
Yes
B
No
If yes, which brand?
Lifestyle
Does your pet:
*
A
Visit Groomer
B
Boarding/Daycare
C
Go to parks
D
None of these
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?
*
A
Yes
B
No
If yes, please explain:
Any major surgical procedures?
*
A
Yes
B
No
If yes, what were they?
Submit