Intake Questionnaire

Pet's Name*

Type of Visit*

General wellness exam

Exam with health concerns

Reason for Visit*

Eating*

Normal

Less than normal

Not eating

If eating is not normal, how long has this been going on? Has anything changed (new food or treats) Do we like to eat things we should not? Are items missing around the house?

What food is your pet currently on(kibble, canned, homemade diet? Any treats or chews? Any people food? If yes, what kind? Do you know roughly how much your pet is fed at each feeding, and how many times a day is he/she fed?

What brand and formula (main protein) are you currently feeding your pet?

Water Intake*

Normal

Less than normal

Not drinking

If there is a change to the amount your pet drinks, how long has this been going on?

Vomiting?*

Yes

No

How long has it been going on? How often a day? What is in the vomit?

Diarrhea?*

Yes

No

How long has it been going on? How often a day? Color/consistency?

Have we recently gotten into anything (trash, compost, fish, etc.?*

Yes

No

If Yes, what did we get into? And when?

Urinating?*

Normally

Not urinating

Difficulty urinating

If urination is not normal, how long has this been going on and what are you seeing?

Coughing?*

Yes

No

Sneezing?*

Yes

No

Do you frequent any of the following (please check all that apply):

Boarding

Grooming

Dog Parks

Day Care Facilities

If yes, what date?

What, if any, medications and/or supplements is your pet on? This includes flea, tick, and heartworm preventatives. Name of drug or supplement, how often it’s given, dosing if you know it:

Is your pet currently on any flea preventative?*

Yes

No

If yes, what product? When was it last applied/dosed?

If you are seeing skin issues, when did they start? Are there certain times of year you see these issues?

What symptoms are you noticing (Scratching? If yes, what part of the body? Rash present? If yes, where?)

Are you noticing any ear issues?

Left

Right

Both

None

If yes, check what you’ve noticed

Scratching At Ears

Rubbing Head on Ground

Odor To Ears

Other