General Health Questionnaire

We believe in the importance of pet health care and wellness. Your day to day observations are of great importance when it comes to your pet's overall wellness.

Please complete this form prior to your consultation so that we can focus on your areas of concern.

Client Details

Client first name

Client last name

Phone number

Email address

Address

Pet Details

Animal name

Animal species (e.g. dog, cat)

Animal breed

Animal sex (e.g. male, female)

Animal age/DoB

Animal microchip

NUTRITION

Other:

Have you noticed any changes in weight?
   No change
   Decreased weight
   Increased weight
   Unsure

Have you noticed any changes in appetite?
   No change
   Decreased appetite
   Increased appetite
   Unsure

Have you noticed any changes in thirst?
   No change
   Decreased thirst
   Increased thirst
   Unsure

BEHAVIOR

Have you noticed any of the following behavioral changes?
   Lameness or limping
   Refusal to jump or climb stairs
   Reluctance to move
   Difficulty rising from lying down
   House soiling
   Sleeping more
   Aggression when petted
   Decreased interest in exercise or walking
   Other

Other:

EXERCISE

Please describe the type of exercise.

Please describe how comfortable your pet is with exercise.

HEALTH

Other:

Have you noticed any lumps?
Yes
No

If yes, please describe the lump and its location on your pet

PARASITE PREVENTION

Is your pet up to date with its parasite prevention e.g. flea, tick, heartworm medication?
Yes
No

Please list the current parasite prevention medications.

OTHER CONCERNS

Please describe any other health concerns.

By submitting this form, I acknowledge that I am the owner or agent representing the pet named above and that the information here is true and correct.

Date today