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info@familypethealth.com
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Patient Exam Questionnaire
Please fill out this exam summary electronically prior to your appointment.
Please enable JavaScript in your browser to complete this form.
Client/Owner Full Name
*
First
Last
Are you a "New" or "Existing" client?
*
New
Existing
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Spouse/Partner Name if applicable
First
Last
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Can we text this number?
*
Yes
No
Secondary Phone
Can we text this number?
Yes
No
Email
*
Your pet's medical/vaccination records may be requested by another provider for services including routine or urgent care, medical specialists, boarding, grooming and adoption services.
*
I hereby authorize and provide for the transfer of my pet's medical records as deemed necessary by Family Pet Health.
I do NOT authorize or provide for the transfer of my pet's medical records.
Your pet's picture or video may be taken while they are with us and used for Family Pet Health’s advertisement (https://familypethealth.com/) or other social media purposes (Facebook, SnapChat, Instagram, etc). Please indicate if you authorize for their pictures/videos to be posted or used.
*
I approve for Family Pet Health to post and use all pictures/videos taken of my pet.
I do NOT authorize Family Pet Health to post or use any pictures/videos taken of my pet.
If you do not authorize for your pet’s picture to be included in our marketing materials/venues we may still use a picture of your pet in our patient records for our internal identification only.
What is your pet's social media account if you have one?
How did you hear about us?
*
Personal Referral
Social Media
Sign/Drove By
New Resident Program
Google Search
Other
Whom shall we thank?
*
If Other, please describe
*
Which one?
*
Facebook
Instagram
YouTube
Twitter
Other
If Other, please explain
*
Has any of your personal information (phone number, email address) changed since your last visit?
*
Yes
No
Phone
*
Email
*
Your pet's medical/vaccination records may be requested by another provider for services including routine or urgent care, medical specialists, boarding, grooming and adoption services.
*
I hereby authorize and provide for the transfer of my pet's medical records as deemed necessary by Family Pet Health.
I do NOT authorize or provide for the transfer of my pet's medical records.
Your pet's picture or video may be taken while they are with us and used for Family Pet Health’s advertisement (https://familypethealth.com/) or other social media purposes (Facebook, SnapChat, Instagram, etc). Please indicate if you authorize for their pictures/videos to be posted or used.
*
I approve for Family Pet Health to post and use all pictures/videos taken of my pet.
I do NOT authorize Family Pet Health to post or use any pictures/videos taken of my pet.
If you do not authorize for your pet’s picture to be included in our marketing materials/venues we may still use a picture of your pet in our patient records for our internal identification only.
I understand that Family Pet Health is a teaching hospital and that my pet may be treated by a veterinary student under the supervision of a licensed veterinary professional. I will share any concerns about the teaching arrangement with the supervising veterinarian.
*
I have read and understand
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)
How old is your cat?
*
How old is your dog?
*
What is your kitten's birthday?
*
What is your puppy's birthday?
Is the upcoming visit a wellness exam or an exam for a sick pet?
*
Wellness Exam
Exam for a sick pet
Do you have pet insurance?
*
Yes
No
No, but I am interested in learning about pet insurance
Name of Insurance Provider
*
Primary Reason for Appointment/Concerns
Please be as detailed as possible
How long has the medical condition existed?
Please list all previous veterinary clinics your pet has visited
*
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
Normal
Straining to Urinate
Decreased
Blood Present
Increased
Dark
Cloudy
Strong/Foul Odor
Is your pet itching/scratching?
Yes
No
How frequently and for how long?
Is your pet currently on flea/tick prevention and heartworm prevention?
Yes
No
What flea/tick and heartworm prevention do you use for your pet?
Is your pet currently on flea/tick prevention?
Yes
No
What flea/tick prevention do you use for your pet?
Is your pet currently on heartworm prevention?
Yes
No
What heartworm prevention do you use for your pet?
How much of the time does your cat spend indoors?
100%
75%
50%
25%
None
What brand of food do you feed your cat?
How much food do you provide for each meal?
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?
0-5 Years
More than 5 years
Never
Where did you obtain your puppy?
Breeder
Pet store
Friend
Shelter
Rescue
Humane society
Other
If other, please elaborate:
How old was your puppy when you obtained him/her?
0-6 weeks
7-8 weeks
9-10 weeks
10 weeks +
Where does your puppy spend most of his/her day?
Indoor
Outdoor
If Indoor, is the puppy mainly in a crate or allowed to free roam?
Crate
Free Roam
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:
Are you actively socializing your puppy?
Yes
No
How?
Do you have other pets in the household?
Yes
No
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?
Yes
No
If so, please describe:
Are there things your puppy is afraid of, anxious about or does not like?
Yes
No
If so, please describe:
Has your puppy shown any of these signs? (Please check all that apply)
Coughing
Sneezing
Itching
Diarrhea
Vomiting
Lack of appetite
Other
None
If other, please describe:
What brand of food do you feed your puppy?
How much do you provide for one meal?
How frequently do you feed your puppy?
Once daily
Twice daily
Three times daily
Any change in water or food consumption?
Yes
No
If yes, please describe:
Any change in frequency of urination or defecation?
Yes
No
If yes, please describe:
Is your puppy currently on flea/tick prevention and heartworm prevention?
Yes
No
What flea/tick and heartworm prevention do you use for your pet?
Does your puppy take or have medications or supplements (over the counter or prescription) applied routinely?
Yes
No
If yes, please specify the medications and/or supplements:
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?
Indoor
Outdoor
If Indoor, is the dog mainly in a crate or allowed to free roam?
Crate
Free Roam
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
No changes
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?
Do you have other pets in the household?
Yes
No
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?
Yes
No
If so, please describe:
Are there things your dog is afraid of, anxious about or does not like?
Yes
No
If so, please describe.
Has your dog shown any of these signs? (Please check all that apply)
Coughing
Sneezing
Itching
Diarrhea
Vomiting
Lack of appetite
Other
If other, please describe:
What brand of food do you feed your dog?
How much food do you provide for each meal?
How frequently do you feed your dog?
Once daily
Twice daily
Three times a day
What dental care do you do with your dog?
Chews
Brushing
Cleanings
Other
None
If other, please describe:
Any change in grooming or sleeping habits?
Yes
No
If so, please describe:
Any change in water or food consumption?
Yes
No
If so, please describe:
Any change in frequency of urination or defecation?
Yes
No
If so, please describe:
Have you noticed any significant weight changes with your dog in recent months?
Yes
No
If so, please describe:
Is your dog currently on flea/tick prevention?
Yes
No
What flea/tick prevention do you use for your pet?
Is your dog currently on heartworm prevention?
Yes
No
What heartworm prevention do you use for your pet?
Does your dog take or have medications or supplements (over the counter or prescription) applied routinely?
Yes
No
If yes, please specify the medications and/or supplements:
Do you do any training with your dog?
Yes
No
If so, please describe:
What are three things you enjoy about your dog?
Do you have any concerns or topics you would like to discuss?
Kitten
Date of Birth
How long has it been since you owned a kitten?
0-5 Years
More than 5 years
Never
Where did you obtain your kitten?
Breeder
Pet store
Friend
Shelter
Rescue
Humane society
Other
If other, please elaborate:
How old was your kitten when you obtained him/her?
0-6 weeks
7-8 weeks
9-10 weeks
10 weeks +
How much of the time does your kitten spend indoors?
100%
75%
50%
25%
None
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?
Yes
No
If yes, please describe:
Does your kitten use scratching posts?
Yes
No
If yes, please describe:
Do you have other pets in the household?
Yes
No
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?
Yes
No
If so, please describe:
Are there things your kitten is afraid of, anxious about or does not like?
Yes
No
If so, please describe:
Has your kitten shown any of these signs? (Please check all that apply)
Coughing
Sneezing
Itching
Diarrhea
Vomiting
Lack of appetite
Other
If other, please describe:
What brand of food do you feed your kitten?
How much food do you provide for each meal?
How frequently do you feed your kitten?
Once daily
Twice daily
Three times a day
Food always available
Any change in water or food consumption?
Yes
No
If yes, please describe.
Any change in frequency of urination or defecation?
Yes
No
If yes, please describe.
Is your kitten currently on flea/tick prevention and heartworm prevention?
Yes
No
What flea/tick and heartworm prevention do you use for your pet?
Does your kitten take or have medications or supplements (over the counter or prescription) applied routinely?
Yes
No
If yes, please specify the medications and/or supplements:
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
How much of the time does your cat spend indoors?
100%
75%
50%
25%
None
How would you describe your cat's litter box usage?
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?
Yes
No
If yes, please describe.
Any changes in activity, such as being more active at night, or sleeping more during the day? Any increase in vocalization?
Yes
No
If yes, please describe.
Does your cat seem disoriented at times or unable to recognize familiar people?
Yes
No
If yes, please describe.
Does your cat seem stiff when moving, slow to rise, or less agile?
Yes
No
If yes, please describe.
Does your cat use scratching posts?
Yes
No
If yes, please describe.
What is your typical routine of activities with your cat each day?
Do you have other pets in the household?
Yes
No
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?
Yes
No
If so, please describe:
Are there things your cat is afraid of, anxious about or does not like?
Yes
No
If so, please describe:
Has your cat shown any of these signs? (Please check all that apply)
Coughing
Sneezing
Itching
Diarrhea
Vomiting
Lack of appetite
Other
If other, please describe:
What brand of food do you feed your cat?
How much food do you provide for each meal?
How frequently do you feed your cat?
Once daily
Twice daily
Three times a day
Food always available
Any change in grooming or sleeping habits?
Yes
No
If yes, please describe:
Any change in water or food consumption?
Yes
No
If yes, please describe:
Any change in frequency of urination or defecation?
Yes
No
If yes, please describe:
Have you noticed any significant weight changes with your cat in recent months?
Yes
No
If yes, please describe:
Is your cat currently on flea/tick prevention and heartworm prevention?
Yes
No
What flea/tick prevention do you use for your pet?
Does your cat take or have medications or supplements (over the counter or prescription) applied routinely?
Yes
No
If yes, please specify the medications and/or supplements:
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?
Fear, Anxiety and Stress (FAS)
Does your pet show any reluctance to getting in the carrier or car?
*
Yes
No
How would you describe your pet's behavior during travel? (select all that apply):
*
eager & excited
subdued
more quiet than usual
more vocal than usual
Does your pet do any of the following during travel?(select all that apply):
*
pant
tremble
pace
hide
drool
vomit
poop
pee
none
Are there any situations that your pet has tried to avoid or seemed to dislike of in the past? (select all that apply):
*
entering the vet hospital
unfamiliar people or animals
being weighed
going into the exam room
being put up on the exam table
having a rectal temperature taken
ear exam
cleaning
nail trim
other
none
If you selected "other", please explain:
*
Has your pet ever been given any supplements or prescribed any medications to help manage his/her fear or anxiety associated with the visit?
*
Yes
No
If so, what was it and what sort of results did you experience?
*
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