Health Questionnaire

Click here to print and fill out the Health Questionnaire Form

Client Name(Required)

Does your pet experience . . . .

Difficulty climbing stairs

Skin or hair coat changes

Difficulty jumping up

Lumps or bumps

Increased stiffness or limping

Excessive scratching

Loss of housetraining

Changes in sleep patterns

Increased thirst

Less enthusiastic greetings

Increased urination

Increased appetite

Changes in activity level

Decreased appetite

Excessive panting


Other changes in breathing pattern

Change in stools


Problems defecating

Circling or repetitive movements

Weight loss

Confusion or disorientation

Weight gain

Excessive vocalization

Difficulty hearing

Less interaction with family

Vision problems

Decreased responsiveness

Bad breath

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Is this the first time this problem has occurred?

My pet is:

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”.

eats people food. (Circle One).

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



Is your pet on monthly flea prevention?

Is your pet on monthly heartworm prevention?

Has your pet missed any doses?

Do you need any REFILLS on medications today?

Does your pet (circle all that apply):

Please let us know ANYTHING else you think we should know about your pet. (Please feel free to write any additional notes or information.)

May we sedate/anesthetize you pet if necessary?

May we x-ray your pet if necessary (Cost $164+)

May we do bloodwork? (Cost $175+)

May we run urinalysis? (Cost $48.50)

May we run a fecal? (Cost $53.00)

May we perform a cytology (ear and skin)? (Cost $48)

May we perform a corneal stain? (Cost $42)

Would you like a microchip placed( permanent identification)? (Cost: $60)

For dogs, may we run a Heartworm Test? (Cost $48)

For cats, may we run a Leukemia & Aids Test? (Cost $56)

Would you like a Genetic Breed & Health Analysis performed? (Cost $250 and takes 4-6 weeks for results)

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Come See Us

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