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


Vomiting


Other changes in breathing pattern


Change in stools


Coughing


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



MM slash DD slash YYYY

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)?

Time

:


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)



Consent(Required)


MM slash DD slash YYYY







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Abilene, TX 79602

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