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Home » Health Questionnaire

Health Questionnaire

Click here to print and fill out the Health Questionnaire Form

Client(Required)

Patient(Required)

Numbers where I can be reached(Required)

Presenting Concern

Does your pet experience. . .

Difficulty climbing stairs

Yes

Difficulty jumping up

Yes

Increased stiffness or limping

Yes

Loss of housetraining

Yes

Increased thirst

Yes

Increased urination

Yes

Changes in activity level

Yes

Excessive panting

Yes

Other changes in breathing pattern

Yes

Coughing

Yes

Circling or repetitive movements

Yes

Confusion or disorientation

Yes

Excessive vocalization

Yes

Less interaction with family

Yes

Decreased responsiveness

Yes

Skin or hair coat changes

Yes

Lumps or bumps

Yes

Excessive scratching

Yes

Changes in sleep patterns

Yes

Less enthusiastic greetings

Yes

Increased appetite

Yes

Decreased appetite

Yes

Vomiting

Yes

Change in stools

Yes

Problems defecating

Yes

Weight loss

Yes

Weight gain

Yes

Difficulty hearing

Yes

Vision problems

Yes

Bad breath

Yes

Date of her last heat cycle

MM slash DD slash YYYY

Ear Cleanser

Shampoo

Other

Please explain, please feel free to write any additional notes or information on a separate paper.

Is this the first time this problem has occurred?

Yes

No, Last occurrence

How long has this problem been occurring

Did it start suddenly or gradually over a period of time?

Did something specific occur that triggered this problem? Weather change? A fall? New treats? Table food? Etc

Have you treated your pet for this problem?

Has it helped?

What have you administered?

My pet is

Indoor Only

Indoor/Outdoor

Outdoor Only

Please let us know what brands and quantities of each food type your pet eats. If your pet does not eat one of these categories, write “NA”.

Dry Food

Canned Food

Treats

My Pet(Required)

Never

Occasionally

Frequently eats people food

People Food

When was the last time your pet ate (food, treats, and people food included)?

Time

Hours

Minutes

AM/PM

Amount

Is your pet on monthly flea prevention?

Yes

If yes, which kind?

Is your pet on monthly heartworm prevention?

Yes

If yes, which kind?

Has your pet missed any doses?

Yes

If yes, how many?

Medications my pet is taking. Please include all medications including drug name, strength, and frequency

Do you need any REFILLS on medications today?

Yes

If yes, which medications?

Supplements my pet is taking. Please include all supplements including brand, name, strength, and frequency

Please describe your pets activity, exercise and frequency

Does your pet(Required)

get tired easily

get winded

get out of breath

limp

Please let us know ANYTHING else you think we should know about your pet.

(Please feel free to write any additional notes or information on a separate sheet of paper.)

May we sedate/anesthetize you pet if necessary?

Yes

Call First

May we x-ray your pet if necessary (Cost $180+)

Yes

Call First

May we do bloodwork? (Cost $192+)

Yes

Call First

We recommend Wellness Screening for our healthy patients. This panel includes CBC (complete blood count), chemistry, Urinalysis, intestinal parasite screening, heartworm testing, & tick borne disease panel. (Cost $240+)

May we run urinalysis? (Cost $62.50)

Yes

Call First

May we run a fecal? (Cost $56.25-73)

Yes

Call First

May we perform a cytology (ear and skin)? (Cost $69.75)

Yes

Call First

May we perform a corneal stain? (Cost $47.50)

Yes

Call First

Would you like a microchip placed (permanent identification)? (Cost $66.50)

Yes

Call First

For dogs, may we run a Heartworm Test? (Cost $52)

Yes

Call First

Would you like a Genetic Breed & Health Analysis performed? (Cost $270.50 and takes test 4-6 weeks for results)

Yes

Call First

For cats, may we run a Leukemia & Aids Test? (Cost $60.50)

Yes

Call First

In addition to the above diagnostics, the maximum to spend if my pet needs additional care is $

I understand my pet will be treated for fleas&/ or ticks at my expense if they are found.

Signed by owner or agent(Required)

PRINT NAME(Required)

Date(Required)

MM slash DD slash YYYY

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318 E. South 11th St.,
Abilene, TX 79602

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318 E. South 11th St.,
Abilene, TX 79602

About Us
Client Resources
Services
Emergencies
Online Store
Contact Us

Business Hours

Monday

7:30am – 5:30pm

Tuesday

7:30am – 5:30pm

Wednesday

7:30am – 5:30pm

Thursday

7:30am – 5:30pm

Friday

7:30am – 5:30pm

Saturday

Closed

Sunday

Closed

Appointments recommended. For after hours emergencies call (325) 691-1504