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Patient Consultation Questionnaire

;

Complete this form before your next visit.

Client's Name *

First

Last

Email *

Patient's Name *

Why is your pet being seen today? *

(i.e., vomiting, diarrhea, lethargy, scratching ears, etc.)

How long has the problem been going on? *

Are you aware of anything that may have caused the symptoms? *

(i.e., my pet got into the trash, my pet fell while getting out of the car, etc.)

Is your pet's activity *

Normal
Increased
Decreased

Is your pet's appetite *

Normal
Increased
Decreased

Is your pet's thirst *

Normal
Increased
Decreased

Is your pet experiencing any of the following symptoms (check all that apply)

Coughing
Sneezing
Vomiting
Diarrhea

Is your pet's coughing *

Clear
Productive
Other

If other, please specify *

Is your pet's sneezing *

Clear
Mucoid
Other

If other, please specify *

Is your pet's vomiting *

Food
Bile
Other

If other, please specify *

Is your pet's diarrhea *

Soft
Liquid
Bloody
Mucoid

Is your pet’s mobility *

Normal
Abnormal

(i.e., any lameness, weakness, dragging toes, etc.)

If abnormal, please describe *

Does your pet have any new masses? *

Yes
No

If yes, where? *

Does your pet have any skin lesions? *

Yes
No

If yes, where? *

What do you feed your pet (please provide name brand and formula of diet)? *

Is your pet on a grain-free or raw diet? *

Grain-free
Raw
Neither

What is the volume of food you offer per day? *

How often is your pet fed? *

Free fed
1x/day
2x/day
Other

If other, please specify *

What kind of treats do you offer your pet? *

How often are treats offered? *

What do you do to help maintain the health of your pet’s teeth at home? *

(i.e., brushing, dental chews, etc.)

How often? *

When was your pet’s last dental cleaning? *

Were dental x-rays performed? *

Yes
No
Unsure

Is your pet on any current medication? *

Yes
No

If yes, please list all current medications *

Is your pet on any supplements? *

Yes
No

(i.e., glucosamine, omega fatty acids, CBD, etc.)

If yes, please list all supplements *

Is your pet on any heartworm prevention? *

Yes
No

If yes, please specify *

Is your pet on any flea and tick prevention? *

Yes
No

If yes, please specify *

Approximate percentage of time your pet spends indoors *

Approximate percentage of time your pet spends outdoors *

Has your pet traveled outside the area in the past 12 months? *

Yes
No

If yes, where? *

Do you plan for your pet to travel outside the area in the coming 6 months? *

Yes
No

If yes, where? *

Do you have pet insurance? *

Yes
No

Name of insurance company *

If you are interested, the Cardiff Animal Hospital will submit claims on your behalf. Please provide us with a blank claim form with your pet’s information pre-printed on it, and we will fax it in after each visit.

Does your pet have a microchip? *

Yes
No
Unsure

If yes, we will scan it at the time of each examination to ensure it is working.

Are there other pets in the household? *

Yes
No

If yes, please provide name, species, and age of each *

Additional Comments

Signature *

Clear Signature

Date *

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