Appointment Questionnaire Owner's Name* First Last Pet's Name*Appointment Date* Appointment Time* : HH MM AMPM Appointment Type*Please choose the type of appointment you are requesting and please provide any helpful information of your observations. (See options below)General Healthy ExamSick CatSick DogGENERAL HEALTHY EXAMHow has your pet been doing overall?Any vomiting, diarrhea, coughing, or sneezing?How is energy level?Eating and drinking well?What food are you currently feeding?How much and how often?Is your pet on any medications?If, so when was the last dose?Which HW/Flea prevention?Any supplements?Any history of vaccine/drug/allergic reactions?Any previous of hx of illness we should be aware of?Any other issues or concerns to discuss today? Itching, scratching, new lumps or bumps, etc?SICK CAT EXAMWhen did it start?Have the signs gotten better or worse?Any change in appetite?What food is your pet eating? How much and how often?Do they get table scraps?Ingestion of leaves, string, etc?Change in type of diet?Any change in water intake?Any change in litterbox use? Frequency? Not using it?How is energy level? Indoor/OutdoorAny other pets in house? If no, is anyone else having symptoms?What medication(s) is your pet taking? When was the last dose?Any supplements/OTC Medication administered?Which HWP? Which flea prevention?Any history of vaccine/drug/allergic reactions?Any other issues or concerns to discuss today?SICK DOG EXAMWhen did it start?When was the last episode?Any change in appetite or water intake?What kind of food are you feeding? How much/how often?How is energy level?Any changes in urination/defecation?Any supplements? Glucosamine?Only pet in house?If no, is anyone else having symptoms?Any history of vaccine/drug/allergic reactions?Any other issues or concerns to discuss today?PhoneThis field is for validation purposes and should be left unchanged.
