EmailMeForm
Wellness Exam Questionnaire
Please complete this form prior to your pet's wellness visit.
Client Name
*
First
Last
Client Email
*
Pet Name
Appointment Date
MM
/
DD
/
YYYY
Any changes to:
Activity Level?
No
Increased
Decreased
Drinking?
No
Increased
Decreased
Eating?
No
Increased
Decreased
Urination?
No
Increased
Decreased
Defecation?
No
Increased
Decreased
Teeth/Gums?
No
Odor
Difficulty Eating
Fur/Skin?
No
Dry/Flaky
Oily
Redness
Itchy
Lumps/Bumps
What else can you tell us about the lumps/bumps?
Other concerns/changes:
Consumption Information
What are you feeding your pet?
Total cups/day:
How often do you feed?
Free Feed
1 time/day
2 times/day
3 times/day
4+ times/day
Please list all medications/supplements that you give your pet:
Additional Information
Is your pet exposed to other animals outside of your home?
Groomer
Boarding/Kennel
Obedience Classes/Play Groups
Dog Park
You can select multiple choices.
Is your pet a working animal?
Service/Therapy Pet
Show/Obedience
Hunting
You can select multiple choices.
Does your pet travel with you to other regions?
Yes
No
What regions did you visit?
Percent of time this pet spends outdoors?
%
Are there any vulnerable people who live at your house or visit regularly? (ex: young children, elderly or immunosuppressed people?)
Yes
No