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Patient Exam Questionnaire
Please fill out this exam summary electronically prior to your appointment.
Client/Owner's Name
(Required)
First
Last
Are you a "New" or "Existing" client?
(Required)
New
Existing
Hidden
New Client Info
Spouse/Partner Name if applicable
First
Last
Phone
(Required)
Can we text this number?
(Required)
Yes
No
Secondary Phone
Can we text this number?
Yes
No
Hidden
End New Client Info
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
(Required)
Hidden
New Client Info
How did you hear about us?
(Required)
Personal Referral
Social Media
Sign/Drove By
New Resident Program
Google Search
Other
Who should we thank?
(Required)
If other, please specify
(Required)
What social media platform?
(Required)
Facebook
Instagram
YouTube
Twitter
Other
If other, please specify
(Required)
Hidden
Existing Client Info
Has any of your personal information (phone number, email address) changed since your last visit?
(Required)
No
Phone
Email
Both
Phone
(Required)
Email
(Required)
Hidden
End Existing Client Info
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.
(Required)
I have read and understand.
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.
(Required)
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?
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.
(Required)
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.
Patient's Name
(Required)
Appointment Date
MM slash DD slash YYYY
Appointment Time
Hours
:
Minutes
AM
PM
AM/PM
Species
(Required)
Canine
Feline
Other
If other, please specify
(Required)
Sex
(Required)
Male
Neutered Male
Female
Spayed Female
Patient Age
(Required)
Puppy (0-12 months)
Adult (1-7 years)
Senior (7+ years)
Patient Age
(Required)
Kitten (0-12 months)
Adult (1-11 years)
Senior (11+ years)
How old is your pet?
(Required)
When is your pet's birthday?
(Required)
Is the upcoming visit a wellness exam or an exam for a sick pet?
(Required)
Wellness Exam
Exam for a sick pet
Do you have pet insurance?
(Required)
Yes
No
No, but I am interested in learning about pet insurance
Name of Pet Insurance Provider
(Required)
Primary Reason for Appointment/Concerns
(Required)
Please be as detailed as possible
Please list all previous veterinary clinics your pet has visited
(Required)
Hidden
Sick Pet Exam
How long has the medical condition existed?
(Required)
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?
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 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 specify
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?
Indoors
Outdoors
If indoors, 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 yes, please describe
Are there things your puppy is afraid of, anxious about, or does not like?
Yes
No
If yes, 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 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/Senior Dog
Where does your dog spend most of his/her day?
Indoors
Outdoors
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?
(Required)
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?
(Required)
Yes
No
If yes, please describe
Are there things your dog is afraid of, anxious about or does not like?
(Required)
Yes
No
If yes, please describe
Has your dog shown any of these signs? (Please check all that apply)
Coughing
Sneezing
Itching
Diarrhea
Vomiting
Lack of appetite
Other
None
If other, please specify
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 daily
What dental care do you do with your dog?
Chews
Brushing
Cleanings
Other
None
If other, please specify
Any change in grooming or sleeping habits?
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 dog in recent months?
Yes
No
If yes, please describe
Is your dog currently on flea/tick or heartworm prevention?
Yes
No
What 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 describe
Do you do any training with your dog?
Yes
No
If yes, please specify the medications and/or supplements:
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?
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 specify
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 yes, please describe
Are there things your kitten is afraid of, anxious about or does not like?
Yes
No
If yes, 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 specify
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 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/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 yes, please describe
Are there things your cat is afraid of, anxious about, or does not like?
Yes
No
If yes, please describe
Has your cat shown any of these signs? (Please check all that apply)
Coughing
Sneezing
Itching
Diarrhea
Vomiting
Lack of appetite
Other
None
If other, please specify
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 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 of the above
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 of the above
If other, please specify
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 yes, what was it and what sort of results did you experience?
Name
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