Annual Physical Pet Questionnaire Pet's Annual Physical Questionnaire Please answer these questions to the best of your abilities. With this comprehensive knowledge our Veterinarians can provide your pets with the best possible service for them. Lets work together so we can continue to preserve that special bond! Owner Information Section Pet Owner Name (Primary Contact) * Pet Owner Name (Primary Contact) First First Last Last Co-Owner Co-Owner First First Last Last Address * Address Address Address City City State State Zip Code Zip Code Primary Phone Type * Cell Landline Primary Phone Number * Secondary Phone Number Co-Owner Primary Phone Type Cell Landline Co-Owner Primary Phone Number * Co-Owner Secondary Phone Number Email * Emergency Contact Name * Emergency Contact Phone Number * Pet Information Section Pet Type * Dog Cat Pet's Name * Is your pet on any medications or supplements? * Yes No Please list all medications or supplements * Appetite * Excellent Good Picky Poor Habitat * Indoor Outdoor In and Out freely Food Type * Kibble Only Kibble & Canned Canned only Raw Main Food Brand * What kind of treats is pet being given? * Diet Frequency * Fed once a day Fed twice a day Fed three times a day Free Fed Water Consumption * Drinks small amount Drinks normal amount Drinks excessive amount Activity Level * Sedentary Normal Energetic Has your pet attended any other Veterinary facility over the past year? * Yes No Please list any other Veterinary facility your pet has attended over the past year * Please list any other pets you might have at home * Does your pet go to a grooming or boarding facility, obedience school, leash free parks or pet shows? * Yes No Has your pet travelled with you out of town/to destination vacations? * Yes No Please indicate where Does your pet hunt? * Yes No Do they eat their prey Yes No Does your pet vomit? * Never/Rarely Occasionally Constantly Does your pet cough? * Never/Rarely Occasionally Constantly Does your pet sneeze? * Never/Rarely Occasionally Constantly Does your pet persistently itch? * No Seasonally Year-round Where on the body? Has your pet experienced any mobility issues? * No Yes On occasion If lameness has been noticed, please state which leg(s) and the duration Any signs of fleas or ticks noticed recently? * Yes No Do you apply flea prevention? * Yes No Please state what kind * Do you give your dog heart worm prevention? * Yes No Please state what kind * Do you get skunks, raccoons, or rodents in your yard or neighborhood? * Yes No Has your cat been involved and/or injured in any fights (cats, raccoons, etc) within the past 2 years? * Yes No Unsure Does your dog have access to rivers, lakes, dams, or ponds? * Yes No Have you noticed any lumps you would like to have checked? If so, please include their approximate locations on body: * Based on the pictures below, what level would you classify your pet as on the Spectrum of Fear, Anxiety and Stress during past veterinary visits? * 0 0-1 1 2 3 4 5 Based on the picture below, which number best describes your pet's stool? * 1 2 3 4 5 6 7 Any additional concerns or comments? Thank you for taking the time to answer all these question so we can better understand your pet for their next visit! Please sign form * Clear reCAPTCHA If you are human, leave this field blank. Submit Clear all fields
