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 *FirstLastAre you a "New" or "Existing" client? *NewExistingSpouse/Partner Name if applicableFirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Can we text this number? *YesNoSecondary PhoneCan we text this number?YesNoEmail *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 MediaSign/Drove ByNew Resident ProgramGoogle SearchOtherWhom shall we thank? *If Other, please describe *Which one? *FacebookInstagramYouTubeTwitterOtherIf Other, please explain *Has any of your personal information (address, phone number, email address) changed since your last visit? *YesNoAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneEmailYour 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.Patient's Name *Appointment Date & TimeDateTimePatient's Species *CanineFelineOtherIf Other, please describe *Patient's Sex *MaleNeutered MaleFemaleSpayed FemalePatient 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 ExamExam for a sick petPrimary Reason for Appointment/ConcernsPlease be as detailed as possibleHow long has the medical condition existed?Has your pet seen another veterinarian? *YesNoName of Clinic *Patient's Energy LevelNormalIncreasedDecreasedPatient's AppetiteNormalIncreasedDecreasedWater Intake/DrinkingNormalIncreasedDecreasedIs the patient coughing?YesNoHow frequently and for how long?Is the patient sneezing?YesNoHow frequently and for how long?Is the patient vomiting?YesNoHow frequently and for how long?Does the patient have diarrhea?YesNoHow frequently and for how long?Patient's UrinationNormalStraining to UrinateDecreasedBlood PresentIncreasedDarkCloudyStrong/Foul OdorIs your pet itching/scratching?YesNoHow frequently and for how long?Is your pet currently on flea/tick prevention and heartworm prevention?YesNoWhat flea/tick and heartworm prevention do you use for your pet?Is your pet currently on flea/tick prevention?YesNoWhat flea/tick prevention do you use for your pet?Is your pet currently on heartworm prevention?YesNoWhat heartworm prevention 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?PuppyDate of BirthHow long has it been since you owned a puppy?0-5 YearsMore than 5 yearsNeverWhere did you obtain your puppy?BreederPet storeFriendShelterRescueHumane societyOtherIf other, please elaborate:How old was your puppy when you obtained him/her?0-6 weeks7-8 weeks9-10 weeks10 weeks +Where does your puppy spend most of his/her day?IndoorOutdoorIf Indoor, is the puppy mainly in a crate or allowed to free roam?CrateFree RoamHow would you describe your puppy's house training?Great, not having any accidentsGood, a few accidents when I forget to take him/her outSo-so, having several accidents a dayNot a clue, most elimination is happening in a location I do not preferComments:Are you actively socializing your puppy?YesNoHow?Do you have other pets in the household?YesNoIf 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?YesNoIf so, please describe:Are there things your puppy is afraid of, anxious about or does not like?YesNoIf so, please describe:Has your puppy shown any of these signs? (Please check all that apply)CoughingSneezingItchingDiarrheaVomitingLack of appetiteOtherIf 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 dailyTwice dailyThree times dailyAny change in water or food consumption?YesNoIf yes, please describe:Any change in frequency of urination or defecation?YesNoIf yes, please describe:Is your puppy currently on flea/tick prevention and heartworm prevention?YesNoWhat 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?YesNoIf 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 DogSenior DogWhere does your dog spend most of his/her day?IndoorOutdoorIf Indoor, is the dog mainly in a crate or allowed to free roam?CrateFree RoamHave you noticed any changes in your dog’s personality or activity level?Less or more activeDifficulty rising after resting or sittingUrine or stool accidents in the houseMore independent, less affectionate, or more dependentDisoriented at times or failure to recognize familiar peopleNo changesComments:How would you describe your dog's house training?Great, not having any accidentsGood, a few accidents when I forget to take him/her out (less than once a month)Could be better, numerous accidents a weekNot a clue, most elimination is happening in a location I do not preferComments:What is your typical routine of activities with your dog each day?Do you have other pets in the household?YesNoIf 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?YesNoIf so, please describe:Are there things your dog is afraid of, anxious about or does not like?YesNoIf so, please describe.Has your dog shown any of these signs? (Please check all that apply)CoughingSneezingItchingDiarrheaVomitingLack of appetiteOtherIf 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 dailyTwice dailyThree times a dayWhat dental care do you do with your dog?ChewsBrushingCleaningsOtherNoneIf other, please describe:Any change in grooming or sleeping habits?YesNoIf so, please describe:Any change in water or food consumption?YesNoIf so, please describe:Any change in frequency of urination or defecation?YesNoIf so, please describe:Have you noticed any significant weight changes with your dog in recent months?YesNoIf so, please describe:Is your dog currently on flea/tick prevention?YesNoWhat flea/tick prevention do you use for your pet?Is your dog currently on heartworm prevention?YesNoWhat heartworm prevention do you use for your pet?Does your dog take or have medications or supplements (over the counter or prescription) applied routinely?YesNoIf yes, please specify the medications and/or supplements:Do you do any training with your dog?YesNoIf so, please describe:What are three things you enjoy about your dog?Do you have any concerns or topics you would like to discuss?KittenDate of BirthHow long has it been since you owned a kitten?0-5 YearsMore than 5 yearsNeverWhere did you obtain your kitten?BreederPet storeFriendShelterRescueHumane societyOtherIf other, please elaborate:How old was your kitten when you obtained him/her?0-6 weeks7-8 weeks9-10 weeks10 weeks +How much of the time does your kitten spend indoors?100%75%50%25%NoneHow would you describe your kitten's litter box training?Great, not having any accidentsGood, a few accidents have occurredNot a clue, most elimination is happening in a location I do not preferComments: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?YesNoIf yes, please describe:Does your kitten use scratching posts?YesNoIf yes, please describe:Do you have other pets in the household?YesNoIf 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?YesNoIf so, please describe:Are there things your kitten is afraid of, anxious about or does not like?YesNoIf so, please describe:Has your kitten shown any of these signs? (Please check all that apply)CoughingSneezingItchingDiarrheaVomitingLack of appetiteOtherIf 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 dailyTwice dailyThree times a dayFood always availableAny change in water or food consumption?YesNoIf yes, please describe.Any change in frequency of urination or defecation?YesNoIf yes, please describe.Is your kitten currently on flea/tick prevention and heartworm prevention?YesNoWhat 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?YesNoIf 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 CatSenior CatHow much of the time does your cat spend indoors?100%75%50%25%NoneHow would you describe your cat's litter box usage?Great, not having any accidentsOK, a few accidents (less than once a month)Could be better, several accidents a weekNot 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?YesNoIf yes, please describe.Any changes in activity, such as being more active at night, or sleeping more during the day? Any increase in vocalization?YesNoIf yes, please describe.Does your cat seem disoriented at times or unable to recognize familiar people?YesNoIf yes, please describe.Does your cat seem stiff when moving, slow to rise, or less agile?YesNoIf yes, please describe.Does your cat use scratching posts?YesNoIf yes, please describe.What is your typical routine of activities with your cat each day?Do you have other pets in the household?YesNoIf 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?YesNoIf so, please describe:Are there things your cat is afraid of, anxious about or does not like?YesNoIf so, please describe:Has your cat shown any of these signs? (Please check all that apply)CoughingSneezingItchingDiarrheaVomitingLack of appetiteOtherIf 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 dailyTwice dailyThree times a dayFood always availableAny change in grooming or sleeping habits?YesNoIf yes, please describe:Any change in water or food consumption?YesNoIf yes, please describe:Any change in frequency of urination or defecation?YesNoIf yes, please describe:Have you noticed any significant weight changes with your cat in recent months?YesNoIf yes, please describe:Is your cat currently on flea/tick prevention and heartworm prevention?YesNoWhat 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?YesNoIf 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 MammalWhen and where did you acquire your exotic petHow often is your pet handled?Do you have any other pets?YesNoIf 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?CommentSubmit
