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Exam Questionnaire

We, at the ANIMAL HOSPITAL OF WAYNESVILLE, thank you for trusting us with the care of your pet. Please take a moment to fill out this form so that we can better provide you and your pet with the appropriate medical care your pet deserves.

Pet Name Date

Leave this empty:

General Health Questions for All Animals


Type of Diet
Brand Name?
Type: Dry
Semi-soft
Canned
Do you leave food out all day? Yes No
Have you changed food or added new?
Table Scraps/Treats? Yes No
What Kind/How Much?

Do You Travel Anywhere With Your Pet? No
Around Town
Out of State
 
Pet Lifestyle? Inside Only (feet never hit the ground)
Inside/Outside (only supervised)
Outside Only
Inside/Outside (Unsupervised)
Inside/Outside (fenced yard)
 
Is Your Pet Around Other Animals or Children? Dogs
Cats
Children
Other Animals

Medication
What Medication(s) is Your Pet On?
Brand Name(s)?
How Often?
Strength?
How long has pet been on medication?
 
What Type of Heartworm and/or Flea Prevention Do You Use?
Brand Names?
How often do you give it?
Do you miss any doses?
 
Describe any illnesses or surgical procedures that your pet has had.
 

If Your Pet is Sick, Please Answer the Following

Primary Complaint
How Long has This Problem Been Going On?
Has Your Pet Been Treated for This Before Here or by Another Veterinarian?
When?      Where?

Appetite
Increased
Decreased
Last time your pet ate?
How much?
Thirst
Increased
Decreased
How long?


Vomiting
Number of times/How often?
Last time it occurred?
Appearance?
Diarrhea (loose bowel movements)
Number of times/How often?
Last time it occurred?
Appearance?


Urination
Frequency/Amount?
Straining? Yes No
Urinating while sleeping? Yes No
Accidents in house? Yes No
Coughing
Moist (productive)
Dry
Choking
Frequency?


Sneezing
No discharge from nose
Watery discharge
Thick/Colored discharge
Frequency?
Eye Discharge
Right only Left only Both
Squinting
Rubbing eye(s)
Appearance?


Pain (leg, neck, back)
What appears to hurt?
Lameness? Yes No
 
If legs, which leg(s)?
Left front Right front
Left rear Right rear
Slow getting up?
Cries out?
Turning in circles?
NOT able to go up and down stairs/jump on furniture?
Skin/Ear Problems
Biting/Scratching/Licking
Where on body?
Sores?
Smelly discharge/debris from ears?
Have you seen any - fleas ticks
Are you a strict monthly user?
Might miss a few doses?


Convulsions/Seizures
How often?
How long?
Has Your Pet Recently Been Exposed To
Other Animals (boarding, grooming, etc.)? Yes No
When?

Any Additional Concerns?

 

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