Medical Questionnaire Owner name* First Last Pet Name* Please describe the reason for your pet’s upcoming visit (Wellness/Sick)*What are the main concerns regarding your pet’s health that you would like to be addressed today?*Has your pet been experiencing any abnormal clinical signs or behaviors?* Yes No Please describe them*How long has your pet been experiencing these signs?* Are there other pets in the house?* Yes No Are they showing any of the same symptoms?* Yes No What type of food are you feeding your pet?* Please list all medications/vitamins/supplements and dosages your pet receives on a regular basis, including heartworm, flea and tick preventives.*Do you need any refills?* Yes No Which medications do you need refilled?*Is there any relevant medical history that the doctor should be aware of?*Is your pet a cat?* Yes No Please let us know if they are indoor only, indoor/outdoor or outdoor only.* Δ
