Intake Questionnaire
Pet’s Name: ________________________
Age: _________
Gender: M / F
Owner’s Name: ________________________ Species: _______________________
Spayed: Y / N
Neutered: Y / N
Reason for visit today: ___________________________________________________________
Have you noticed any of the following? (please circle all that apply)
Vomiting
Lethargy
Diarrhea
Trouble with stairs or
Coughing
getting in car
Sneezing
Weakness
Increased Drinking
Limping
Increased Urination
Straining to defecate
Accidents in the house
Straining to urinate
Lumps or bumps
Odor to breath
Scooting bottom on the
ground
Blood in urine
Blood in stool
Parasites (fleas / ticks/
worms in stool)
Seizures
Abnormal behavior
Itching
Preventative Care
Is your pet on monthly heartworm preventative?
Yes
No
What brand do you use?
Heartguard
Trifexis
Sentinel
Other: ____________________
Do you use the preventative year round or seasonally?
____________________________
Is your pet on monthly flea and tick preventative?
Yes
No
What brand do you use?
Advantage
Advantix
Preventic Collar
Seresto Collar
Other: ____________
Do you use the preventative year round or seasonally?
____________________________
Any additional flea/tick products you use on your pet? ______________________________
Do you use any of the following to care for your pets teeth?
Daily brushing Occasional Brushing Maxiguard
T/D dental diet
Current Diet: Brand: ___________________ Canned or Dry? __________________________
Meals per day: 1
2
3
4
Volume fed per feeding: _____________________
People food? _______________________________ Treats? ___________________________
Medical Care
Notable medical history: (please circle all that apply)
Heart disease
Kidney disease
Arthritis
Vaccination reaction
Spinal/back disease
Bladder stones
Adverse reaction to anesthesia
Adverse reaction to medication
Allergies
Dental disease
Ear infections
Respiratory disease
Autoimmune disease
Lyme or other tick disease
Urinary tract infection
Neurological disease
Thyroid disease
Skin disease
Ocular disease
Gastrointestinal disease
Other History: ________________________________________________________________________________________________
____________________________________________________________________________________________________________
______________________________________________________________
Current medications? (please include any medications given in the last 30 days, including aspirin or over the counter medications):
___________________________________________________________________________________________________________
Current supplements: _________________________________________________________________________________________