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

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)

What is your preferred Pharmacy?

CountrySide Veterinary Services

CountrySide Veterinary Health

CountrySide Online Store

Other

Please specify your preferred pharmacy

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)

Increase/Decrease in Appetite

Increase/Decrease in Drinking

Increase/Decrease in Weight

Change in Frequency of Urination/Amount of Urine

Any Diarrhea or Vomiting (please note in the box below how often and any specific time of day)

Problems with Control of Urination or Bowel Movements

Behavioral Changes/Abnormal Behavior (i.e. increased aggression, disinterested, uncharacteristic behaviors)

Apparent Confusion, Disorientation, Pacing, or Imbalance Concerns

Irregular Sleep Patterns/Restless at Night

Limping, Stiff Gait, Discomfort, or Trouble Doing Normal Daily Activities

Lethargy

Itchy, Irritated, and/or Flaky Skin

Any New or Changing Masses or Lumps

Any Head Shaking, Dirty Ears, or Scratching Obsessively at Ears

Any Coughing and/or Sneezing (please note in the box below, if the cough is productive/non-productive and if nasal discharge is colored or clear)

Any Concerns with Oral Health

No Concerns

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:

Daycare

Dog Park

Grooming

Pet Store

Camping

Swimming

Hunting

Cat or Dog Show

Hiking

Travel

None of the above

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

If you selected yes for vaccine reactions, please describe.

Is this appointment for a new puppy/kitten?(Required)

Yes

Where did you get your new pet (private home, rescue, breeder, etc)?

How long will you have had your pet at the time of your first visit?

Has your pet been dewormed? If yes, please provide the dates and the products used.

It is important that you submit, or bring along with, a copy of your pets records to your appointment. Regardless of the deworming status, we recommend bringing a fresh fecal sample to your appointment to screen for intestinal parasites.

Has your pet been vaccinated previously? If yes, please provide dates and products used.

It is important that you submit or bring a copy of your pet’s records you to your appointment.

Do you plan on:

Spaying/Neutering

Breeding

Unsure

Will your pet be attending any training or obedience classes? If so, where?

Are you familiar with pet insurance?

Yes

Would you like more information regarding pet insurance?

Yes

If your pet already has an insurance policy, please indicate the provider below.

If your pet has any previous medical records, please email them to [email protected].

Wellness Questionnaire