Exam Questionnaire

Client name:*

First Last

Spouse or other responsible party:*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone*

Cell:

Email*

Pet owner’s date of birth*

Pets Name*

Animal*

Age*

Sex*

Breed*

Primary Reason for Today’s Visit:*

Date*

Would you like your pet's nails trimmed today?*

Yes
No

Stay for a bath?*

Yes
No

For Cats Only:

Indoor
Outdoor
Both

Does your pet have a microchip?*

Yes
No

Do you feed any RAW MEAT DIET?*

Yes
No

Give table/people food?*

Yes
No

Type of food*

Canned
Dry
Both

Food Brand

Is your pet taking any long term prescriptions, over the counter drugs or herbal remedies?*

Yes
No

If yes, please specify:*

Does your pet have any known allergies to ANY medications?*

Yes
No

Does your pet have any chronic medical problems?*

Yes
No

Is your pet on flea control?*

Yes
No

If yes, what kind?*

Do you need any refills?*

Yes
No

Describe any dental home care:*

Does your pet show any of the following symptoms?

We like to use (positive) cute pictures of our patients on our websites and displays when we catch them, but we do need your permission:*

I authorize the use of my pet’s images for social media, displays, newsletters or website.

Signature

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