Why are you bringing your pet in today?

What is the duration of this problem? (How many days, weeks, months, years?)

Has your pet had any vomiting? (Y/N/Duration):

Has your pet had any diarrhea? (Y/N Duration):

Has your pet’s appetite increases/decreased/stayed the same?

What time did your pet last eat?

Has your pet’s urination increased/decreased/stayed the same?

Has your pet been coughing? (Y/N Duration):

Has your pet been sneezing? (Y/N Duration):

If your pet is an unaltered (unspayed) female, when was her last heat cycle?

If your pet is a cat, are they indoor only/outdoor only/both indoor and outdoor?

Has your pet been to a boarding/grooming/daycare facility recently?

What Heartworm/Flea/Tick medication is your pet taking?

When was this medication last given?

Is your pet currently taking any other medications or supplements? If yes, please tell us the Medication, Date last given and Time last given down below.

What diet (food and treats) do you feed to your pet? Please include brand, amount, frequency.

Is your pet microchipped?

If no, would you like your pet to be microchipped today? If unknown we will check for a microchip and notate your pets chart accordingly.

Has your pet had procedures in the past which have resulted in a negative reaction?

If yes please provide details so we can make your pets visit as comfortable and low stress as possible.

Are there areas of your pet’s body they do not like touched? State Yes or No, if Yes, where?

If receiving vaccines today, does your pet have a history of vaccine reactions?

Any additional information you would like the doctor to know please list below.

What Medication do you need refilled?

What Prevention do you need refilled?

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