History Questionnaire for Annual Well Pet Visits Client Name * Pet Name * Date of Visit * Phone Number * Email * Has your pet had any previous vaccine reactions? If so, what was it? Has your pet had recent vomiting, diarrhea, coughing or sneezing? Yes No If yes, please describe: Duration Frequency What is your pet’s current diet (brand/ type)? * Amount per day * Is it grain-free? * Treats Table Food Nutritional Supplements Routine Dental Care at Home: * Medications * Any bad reactions to medications? * Has your pet shown any changes in eating, drinking, urination, or defecation? Yes No If yes, please describe: What do you use for heartworm prevention (dogs)? * Year round? Yes No What do you use for flea/tick prevention? * Year round? Yes No Cats: Indoor or Outdoor? Indoor Outdoor Does your pet have any new lumps or ones that have changed or grown? * Yes No If yes, please describe: Do you want them aspirated (checked under the microscope)? * Yes No Is your pet having any other concerns? (ex. Skin, ears, toe nails, teeth, behavior) * Yes No If yes, please describe: Does your pet have any chronic health concerns? (kidney disease, heart disease, hyperthyroidism, allergies, diabetes, etc) Comments Captcha Submit If you are human, leave this field blank. Δ