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(802) 879 6311
129 Main St, Essex Junction, Vermont 05452
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Pet Health Questionnaire
Please note, this form is to be used for scheduled appointments only
Pet Health Questionnaire
Pet's Name
*
Client's Name
*
Phone Number
If utilizing curbside service
Has your pet had any of the following? Please check all that apply;
*
Coughing
Sneezing
Vomiting
Diarrhea
Increased Drinking
Increased urination
None of these
Please Describe (What is it like? When did it start?):
*
Have you noticed any changes in behavior or activity level?
*
Yes
No
If so, please describe:
*
Are there any new lumps or bumps you’ve noticed and would like examined today?
*
Yes
No
If so, please describe. Where are they located? How long have they been present? Have they changed in size or feel? Do they bother your pet?
*
Have you noticed any new lameness, soreness, or stiffness?
*
Yes
No
If so, please describe: Where are they most sore/lame? How long have you noted this? What activities do they have trouble doing that they used to be able to
*
What food do you feed your pet? (Please note the brand of the food, how much you feed, and treats, etc.)
*
Are there any medications or supplements you give your pet?
*
Yes
No
If so - please note the medication/supplement, how much you give, and how often you give it.
*
Do you give your pet flea and tick medication?
*
Yes
No
If so what brand do you use? Do you give it seasonally or year round?
*
Do you give your pet Heartworm preventative?
*
Yes
No
If so what brand do you use? Do you give it seasonally or year round?
*
Do you need refills of any medications while you are in today?
*
Yes - in-clinic refill
Yes - online pharmacy refill
No
If so, please list name of medication/supplement and quantity:
*
Are there any specific issues/concerns you would like addressed today?
*
If your pet is due for vaccinations within the next month, would you like those given today?
*
Yes
No
Please note: rabies vaccination is required by law
Are you interested in running wellness bloodwork today if recommended?
*
Yes
No
Please provide me with an estimate
Routine wellness bloodwork is recommended every 2-3 years for young and adult pets and every 6 months to yearly for senior pets
DOGS: If your dog is due for their Heartworm and tickborne disease test, may we run it?
Yes
No
Please provide me with an estimate
Heartworm and tickborne disease testing is recommended yearly.
CATS: Does your cat go outside at all?
Yes
No
N/A
Δ
Home
New Clients
About
Meet Our Team
Take A Tour
Promotions
Careers
Services
Anesthesia and Patient Monitoring
Exotic Pet Medicine and Surgery
Health Certificates
Laser Therapy
Medical Services
Nutritional Counseling
Preventive Services
Surgical Services
Veterinary Dentistry
Wellness and Vaccination Programs
Additional Services
Pet Health
Pet Health Checker
Pet Health Library
Pet Food Recalls
Pet Insurance
Product Recalls
How-To Videos
News
Pet Portal
Pet Records
Refill Requests
Mobile App
Pharmacy
Online Pharmacy
Purina Vet Direct
Contact
Pet Health Questionnaire
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