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360-459-6556
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8919 Martin Way East
Lacey, WA, 98516
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today:2023-10-01
Intake Questionnaire
Fill out this form before your next appointment.
Your Name
*
Best Contact Number For This Appointment
*
Pet's Name
*
Reason For Visit
*
Eating
*
Normal
Less than normal
Not eating
If eating is not normal, how long has this been going on? Has anything changed (new food or treats) Do we like to eat things we should not? Are items missing around the house?
What food is your pet currently on(kibble, canned, homemade diet? Any treats or chews? Any people food? If yes, what kind? Do you know roughly how much your pet is fed at each feeding, and how many times a day is he/she fed?
Water Intake
*
Normal
Less than normal
Not drinking
If there is a change to the amount your pet drinks, how long has this been going on?
Vomiting
Yes
No
How long has it been going on? How often a day? What is in the vomit?
Diarrhea
*
Yes
No
How long has it been going on? How often a day? Color/consistency?
Yes
No
Have we recently gotten into anything (trash, compost, fish, etc.?
Yes
No
If Yes, what did we get into? And when?
Urinating?
Normally
Not Urinating
Difficulty Urinating
If urination is not normal, how long has this been going on and what are you seeing?
Coughing
Yes
No
Sneezing
Yes
No
Do you frequent any of the following (please check all that apply):
Boarding
Grooming
Dog Parks
Day Care Facilities
If yes when what date?
What, if any, medications and/or supplements is your pet on? This includes flea, tick, and heartworm preventatives. Name of drug or supplement, how often it’s given, dosing if you know it:
Is your pet currently on any flea preventative?
Yes
No
What product? When was it last applied/dosed?
If you are seeing skin issues, when did they start? Are there certain times of year you see these issues?
What symptoms are you noticing (Scratching? If yes, what part of the body? Rash present? If yes, where?)
Are you noticing any ear issues?
Left
Right
Both
None
If yes, check what you’ve noticed:
Scratching At Ears
Rubbing Head on Ground
Odor To Ears
When did the ear issue start?
What other important information should we know about your pet? Is there previous medical history/history of illness or injury that we should know?
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