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Appointment Questionnaire
Appointment Questionnaire
Appointment Questionnaire
Name
First
Last
Pet's Name
A change in appetite?
Yes
No
Weight gain or weight loss?
Yes
No
Excessive scratiching or itching?
Yes
No
Lumps or bumps?
Yes
No
Dental Problems? (i.e bad breath, tartar, blood in mouth)?
Yes
No
Stiffness on rising, less willing to jump into the car?
Yes
No
Decreased energy levels?
Yes
No
Coughing, sneezing or difficulty breathing?
Yes
No
Vomiting?
Yes
No
Change in bowel movements (consistency or frequency)?
Yes
No
Change in drinking/urination (circle-less or more)?
Yes
No
Eye problems (vision changes, discharge)?
Yes
No
Ear problems (head shaing, scratching, odor, discharge)?
Yes
No
Flea or ticks?
Yes
No
Do you board your pet, take to day care or grooming?
Yes
No
For Dogs:
Travel out of State?
Yes
No
Monthly heartworm preventative?
Yes
No
For Cats:
Does your cat go outside or come into contact with other cats?
Yes
No
Please list all the medications and supplements your pet currently receives.
Add
Remove
What do you feed your pet, how much and how often?
Please note any conerns you have that are not on this list so we can address them as well.
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What's Next
1
Call us or schedule an
appointment online.
2
Meet with a doctor for
an initial exam.
3
Put a plan together for
your pet.
Make An Appointment