Client/Owner Full Name *

First

Last

Are you a "New" or "Existing" client? *

New
Existing

Spouse/Partner Name if applicable

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Can we text this number? *

Yes
No

Secondary Phone

Can we text this number?

Yes
No

Email *

What is your pet's social media account if you have one?

How did you hear about us? *

Whom shall we thank? *

If Other, please describe *

Which one? *

If Other, please explain *

Has any of your personal information (address, phone number, email address) changed since your last visit? *

Yes
No

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Patient's Name *

Appointment Date & Time

Date

Time

Patient's Species *

Canine
Feline
Other

If Other, please describe *

Patient's Sex *

Male
Neutered Male
Female
Spayed Female

Patient Age *

Puppy (0-12 months)
Adult (1-7 years)
Senior (7+ years)

Patient Age *

Kitten (0-12 months)
Adult (1-11 years)
Senior (11+ years)

Patient Age *

Is the upcoming visit a wellness exam or an exam for a sick pet? *

Wellness Exam
Exam for a sick pet

Primary Reason for Appointment/Concerns

Please be as detailed as possible

How long has the medical condition existed?

Has your pet seen another veterinarian? *

Yes
No

Name of Clinic *

Patient's Energy Level

Normal
Increased
Decreased

Patient's Appetite

Normal
Increased
Decreased

Water Intake/Drinking

Normal
Increased
Decreased

Is the patient coughing?

Yes
No

How frequently and for how long?

Is the patient sneezing?

Yes
No

How frequently and for how long?

Is the patient vomiting?

Yes
No

How frequently and for how long?

Does the patient have diarrhea?

Yes
No

How frequently and for how long?

Patient's Urination

Is your pet itching/scratching?

Yes
No

How frequently and for how long?

What flea/tick prevention do you use for your pet?

What heartworm preventative do you use for your pet?

What, if any, medications or supplements (over the counter or prescription) does your pet take or have applied routinely?

Puppy

How long has it been since you owned a puppy?

Where did you obtain your puppy (breeder, pet store, friend, shelter, rescue, humane society, other)?

How long have you had your puppy?

How old was your puppy when you obtained him/her?

How many puppies were in the litter?

How old were the puppies when they were taken away from their mother?

Where does your puppy spend most of his/her day? (inside, outside, in a room, in a kennel, with you)?

How would you describe your puppy's house training?

Great, not having any accidents
Good, a few accidents when I forget to take him/her out
So-so, having several accidents a day
Not a clue, most elimination is happening in a location I do not prefer

Comments:

Have your enrolled your puppy in a puppy socialization class? If so, where?

If you have other pets in the household, describe the puppy’s relationship with them.

Has your puppy ever shown any growling, barking, snarling or mouthing/biting towards you or anyone else? If so, when?

Are there things your puppy is afraid of or does not like? If so, please describe.

Has your puppy shown any of these signs: coughing, sneezing, itching, diarrhea, vomiting, or lack of appetite?

What brand of food do you feed your puppy? How much do you provide and how frequently? Is food available all the time or at set "meal times?" What treats do you offer?

Any change in water or food consumption?

What dental care (chews, brushing, cleanings) do you do with your puppy?

Any change in frequency of urination or defecation?

What flea/tick prevention do you use for your pet?

What heartworm preventative do you use for your pet?

What, if any, medications or supplements (over the counter or prescription) does your puppy take or have applied routinely?

What are three things you enjoy about your puppy?

Do you have any concerns or topics you would like to discuss?

Adult Dog

Senior Dog

Where does your dog spend most of his/her day? (inside, outside, in a room, in a kennel, with you)?

Have you taken your dog to a training class? If so, where?

Do you train your dog? If so, how? (with treats, clicker training, etc)

Do you walk your dog? If so what type of collar does your dog wear for walks?

If not, why?

Any problems with walking your dog?

Have you noticed any changes in your dog’s personality or activity level?

Less or more active
Difficulty rising after resting or sitting
Urine or stool accidents in the house
More independent, less affectionate, or more dependent
Disoriented at times or failure to recognize familiar people

Comments:

How would you describe your dog's house training?

Great, not having any accidents
Good, a few accidents when I forget to take him/her out (less than once a month)
Could be better, numerous accidents a week
Not a clue, most elimination is happening in a location I do not prefer

Comments:

What is your typical routine of activities with your dog each day?

If you have other pets in the household, describe the dog’s relationship with them.

Has your dog ever shown any growling, barking, snarling or mouthing/biting towards you or anyone else? If so, when?

Are there things your dog is afraid of or does not like? If so, please describe.

Has your dog shown any of these signs: coughing, sneezing, itching, diarrhea, vomiting, or lack of appetite?

Any change in grooming or sleeping habits?

Any change in water or food consumption?

What brand of food do you feed your dog? How much do you provide and how frequently? Is food available all the time or at set "meal times?" What treats do you offer?

What dental care (chews, brushing, cleanings) do you do with your dog?

Any change in frequency of urination or defecation?

Have you noticed any significant weight changes with your dog in recent months?

What flea/tick prevention do you use for your pet?

What heartworm preventative do you use for your pet?

What, if any, medications or supplements (over the counter or prescription) does your dog take or have applied routinely?

What are three things you enjoy about your dog?

Do you have any concerns or topics you would like to discuss?

Kitten

How long has it been since you owned a kitten?

Where did you obtain your kitten (breeder, pet store, friend, shelter, rescue, humane society, other)?

How long have you had your kitten?

How old was your kitten when you obtained him/her?

How many kittens were in the litter?

How old were the kittens when they were taken away from their mother?

Where does your kitten spend most of his/her day? (inside, outside, in a room, in a kennel, with you)?

How would you describe your kitten's litter box training?

Great, not having any accidents
Good, a few accidents have occurred
Not a clue, most elimination is happening in a location I do not prefer

Comments:

How many litter boxes do you have and where are they located?

What is the size and type of litter boxes (covered, uncovered, automatic, oval, large rectangular, etc)?

What type and brand of litter do you use? (scented or unscented, clumping versus clay)

Does your kitten like to play with toys? What type?

Does your kitten use scratching posts?

Have your enrolled your kitten in a kitten class? If so, where?

If you have other pets in the household, describe the kitten’s relationship with them.

Has your kitten ever shown any growling, hissing, or mouthing/biting towards you or anyone else? If so, when?

Are there things your kitten is afraid of or does not like? If so, please describe.

Has your kitten shown any of these signs: coughing, sneezing, itching, diarrhea, vomiting, or lack of appetite?

Any change in water or food consumption?

What brand of food do you feed your kitten? How much do you provide and how frequently? Is food available all the time or at set "meal times?" What treats do you offer?

Any change in frequency of urination or defecation?

What flea/tick prevention do you use for your pet?

What heartworm preventative do you use for your pet?

What, if any, medications or supplements (over the counter or prescription) does your kitten take or have applied routinely?

What are three things you enjoy about your kitten?

Do you have any concerns or topics you would like to discuss?

Adult Cat

Senior Cat

Where does your cat spend most of his/her day? (inside, outside, in a room, in a kennel, with you)?

How would you describe your cat's litter box training?

Great, not having any accidents
OK, a few accidents (less than once a month)
Could be better, several accidents a week
Not a clue, most elimination is happening in a location I do not prefer.

Comments:

How many litter boxes are in the home and where are they located?

What is the size and type of litter boxes (covered, uncovered, automatic, oval, large rectangular, etc)?

What type of litter do you use and what brand? (scented or unscented, clumping versus clay)

Does your cat like to play with toys? What type?

Any changes in activity, such as being more active at night, or sleeping more during the day? Any increase in vocalization?

Does your cat seem disoriented at times or unable to recognize familiar people?

Does your cat seem stiff when moving, slow to rise, or less agile?

Does your cat use scratching posts?

What is your typical routine of activities with your cat each day?

If you have other pets in the household, describe the cat’s relationship with them.

Has your cat ever shown any growling, hissing, or mouthing/biting towards you or anyone else? If so, when?

Are there things your cat is afraid of or does not like? If so, please describe.

Has your cat shown any of these signs: coughing, sneezing, itching, diarrhea, vomiting, or lack of appetite?

Any change in grooming or sleeping habits?

Any change in water or food consumption?

What brand of food do you feed your cat? How much do you provide and how frequently? Is food available all the time or at set "meal times?" What treats do you offer?

Any change in frequency of urination or defecation?

Have you noticed any significant weight changes with your cat in recent months?

What flea/tick prevention do you use for your pet?

What heartworm preventative do you use for your pet?

What, if any, medications or supplements (over the counter or prescription) does your cat take or have applied routinely?

What are three things you enjoy about your cat?

Do you have any concerns or topics you would like to discuss?

Small Mammal

When and where did you acquire your exotic pet

How often is your pet handled?

Do you have any other pets?

Yes
No

If yes, how many and what type?

What type and size of enclosure/cage does your exotic pet live in?

What type of bedding/substrate do you use?

How often is the cage/enclosure cleaned?

What type of disinfectant do you use?

Type and Brand of food being offered?

How often?

Supplements?

How often?

Patient Exam Questionnaire

Puppy

Adult Dog

Senior Dog

Kitten

Adult Cat

Senior Cat

Small Mammal