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Wellness Visit Questionnaire

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What is your pets name:

*

Owners name:

*

Date:

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General Health:

Has your pet had any of the following?

*

Has your pet had any of the following?

Coughing

Sneezing

Vomiting

Diarrhea

Any changes in urination or bowel movements?

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Straining

*

Accidents

Increased Frequency

Blood

Normal

Any lumps, bumps, or new growths you’d like checked out?

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A

Yes

*

B

No

If yes, where?

*

Any change in drinking habits, appetite, weight, or behavior?

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A

Yes

*

B

No

If yes, where?

*

Preventatives:

Is your pet currently on any heartworm prevention?

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A

Yes

*

B

No

If yes, which brand?

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Is your pet on flea/tick preventation?

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A

Yes

*

B

No

If yes, which brand?

*

Lifestyle:

Does your pet:

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Visit Groomer

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Boarding/Daycare

Go to parks

None of these

Go swimming/hunting?

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A

Yes

*

B

No

Medications & Other Notes:

Is your pet currently on any medication?

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A

Yes

*

B

No

Please List:

*

Does your pet have any long-term health issues or past diagnoses we should know about?

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A

Yes

*

B

No

If yes, please explain:

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Any major surgical procedures?

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A

Yes

*

B

No

If yes, what were they?

*