Name: *

First

Last

Email: *

Phone: *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

1. Main Concerns

What are your main concerns or goals for today’s visit? *

2. Pre-existing Medical Conditions

your estimate name,

Does your pet have any current/chronic medical conditions? *

Yes
No

If yes, please describe: *

3. Recent Changes

Since your pet’s last visit, have you noticed any changes in: *

Please describe any changes you checked: *

4. Medications & Preventatives

Is your pet currently taking any medications, supplements, or preventatives? *

Yes
No

If yes, please list the name, dose, and how often each is given: *

Any recent changes in medications or diet? *

Yes
No

If yes, please explain: *

5. Reactions or Sensitivities

How does your pet typically behave at the vet? *

If other, please describe: *

Has your pet ever had a reaction to a vaccine, medication, or food? *

Yes
No

If yes, please describe: *

6. Lifestyle & Environment

Which best describes your pet’s lifestyle? *

Indoor only
Outdoor only
Indoor/Outdoor
Other

If other, please describe: *

Does your pet: *

Visit a groomer, daycare, or boarding facility?
Go to dog parks or pet-friendly places?
Live with or regularly interact with other pets?
Other

If other, please provide details: *

7. Nutrition

What food(s) does your pet eat (brand, type, frequency)? *

Have you noticed any changes in eating habits? *

Yes
No

If yes, please describe: *

8. Additional Information

Is there anything else you’d like the doctor or staff to know before your appointment? *

Would you like to review an estimate before services are performed? *

Yes
No

Signature *

Clear Signature

Pre-Visit Questionnaire

1. Main Concerns

2. Pre-existing Medical Conditions

3. Recent Changes

4. Medications & Preventatives

5. Reactions or Sensitivities

6. Lifestyle & Environment

7. Nutrition

8. Additional Information