Patient History Questionnaire Please completely fill out the Patient History Questionnaire form prior to your appointment. Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Pet's Name *Why is your pet coming to see us? *Wellness VisitIllness VisitPrimary concern for your visit with us *Species *DogCatWhat services would you like your cat to receive while here (select all that apply) *Rabies vaccineFecal analysisFeline distemper vaccineAnnual wellness labworkOtherIf other, please specify *What services would you like your dog to receive while here (select all that apply) *Rabies vaccineCanine distemper vaccineKennel cough vaccineAnnual wellness labworkFlu vaccineHeartworm testFecal analysisOtherIf other, please specify *What is your pet eating? (check all that apply) *Dry foodWet foodTreatsDry Food - Brand *Dry Food - Flavor *Dry Food - Quantity per serving *Dry Food - Frequency per day *Wet Food - Brand *Wet Food - Flavor *Wet Food - Quantity per serving *Wet Food - Frequency per day *Treats - Brand *Treats - Flavor *Treats - Quantity per day *Treats - Frequency per day *Has your pet been eating normally? *YesNoWhat are your concerns with how your pet is eating? *Does your pet have any chew toys? *YesNoWhat types of toys are they? *How is your pet’s water consumption? *NormalIncreasedDecreasedIs your pet on heartworm preventative? *YesNoHeartworm preventative brand *How often do you adminster it? *Once per monthOnly in the spring/summerWhen I rememberOtherIf other, please explain *Is your pet on tick preventative? *YesNoTick preventative brand *How often do you adminster it? *Once per monthOnly in the spring/summerWhen I rememberOtherIf other, please explain *Is your pet on any other medications? *YesNoMedication name & dosage (in milligrams) *Dose given per day *Is your pet on any other medications? *YesNoMedication name & dosage (in milligrams) *Doses given per day *Is your pet on any other medications? *YesNoMedication name & dosage (in milligrams) *Doses given per day *Is your pet on any supplements? *YesNoSupplement name & dosage *Doses given per day *Is your pet on any other supplements? *YesNoSupplement name & dosage *Doses given per day *Is your pet on any other supplements? *YesNoSupplement name & dosage *Doses given per day *Has your pet had any of the following (check all that apply): *CoughingSneezingDiarrheaVomitingNone of the aboveWhen did the coughing first start? *How often is the coughing occurring? *When did the sneezing first start? *How often is the sneezing occurring? *When did the diarrhea first start? *How often is the diarrhea occurring? *Describe the appearance (watery, mucous, bloody, etc.) *When did the vomiting first start? *How often is the vomit occurring? *Describe the appearance (color, contents, etc.) *Does your pet have any lumps or bumps that you would like looked at? *YesNoWhere are the lumps or bump located? *Has your pet had any issues with their skin? *YesNoWhat have you noticed? *Has your pet had any ear issues? *YesNoWhat type of issues have you noticed? *How many minutes of exercise is your pet getting per day? *None15-30 minutes30-60 minutesMore than 60 minutesHow’s your pet’s energy level? *PoorNormalExtra energyDoes your pet go outside? *YesNoDoes your pet go for walks? *YesNoHow do you walk your pet? *On-leashOff-leashDo you board your pet? *YesNoDo you take your pet to a groomer? *YesNoDo you take your pet to daycare? *YesNoAny travel history outside of New England? *YesNoWhere did your pet travel? *When did your pet travel? *Does your pet see any other veterinarians or animal care specialists? *YesNoName of veterinarian or animal care specialist *Do you have insurance for your pet? *YesNoCompany Name *Do you have any other questions or concerns that you would like to discuss at your pet’s appointment?Have you had any contact with people known or suspected to have COVID-19 in the prior 14 days? *YesNoNameSubmit
