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Wellness Exam Questionnaire

Please answer all questions, prior to the appointment date, to the best of your ability. If you are unsure or have questions, please mark “Unsure” or “Unknown”.

First Name(Required)

Last Name(Required)

Email Address(Required)

Phone Number(Required)

Patient Name(Required)

Species(Required)

Sex(Required)

Spay/Neutered(Required)

Is your pet microchipped?(Required)

Yes

No

Unsure

Age(Required)

If your pet is new to us, please provide a birthdate or approximate age.

Medications : Please list all current medications/supplements, including dosage and frequency.(Required)

Food: Please list your pet's current diet. Include the brand, flavor, amount, and frequency.(Required)

Medical Concerns: Please check each symptom, that applies to your pet, below.(Required)

Medical Concerns: Please provide details on any of the medical concerns selected above.

Lifestyle: What would you say best describes your pets lifestyle?(Required)

Indoor

Outdoor

Both

Do you have any additional pets in your home? If so, are they indoor or outdoor? Please list all in the box below.(Required)

Please check any extracurricular activities that your pet participates in:

If you selected travel above, please specify where the travel takes place and the method of travel.

Is your pet currently on heartworm prevention? If so, please list the product and frequency of administration.(Required)

Is your pet currently on flea/tick prevention? If so, please list the product and frequency of administration.(Required)

Has your pet had any previous vaccine reaction(s)? (i.e. vomiting, diarrhea, lethargy, soreness, swelling, or hives)(Required)

Yes

No

If you selected yes for vaccine reactions, please describe.