Patient History Questionnaire for Sick Visits

Client Name*

First Last

Pets Name*

Type of Pet*

Dog
Cat

Breed*

Approximate age*

Date of Appointment*

Time of Appointment*

:

What is the main reason for your pet’s visit?*

What questions if any do you have for the doctor?*

Please answer the questions below.

What is your pets current diet (food type, brand, how much you feed and how many times of day, plus any treats and quantity given)?*

Have your pet’s eating habits changed?*

No, they are eating normally
Yes

Please explain*

Have your pet’s drinking habits changed?*

No, they are eating normally
Yes

Please explain*

Have your pet’s bathroom habits changed?*

No, they are urinating and defecating normally
Yes

Please explain (accidents in the house, urinating outside the litter box, diarrhea, constipation, etc).*

Is your pet vomiting?*

No
Yes

Describe*

Is your pet experiencing any coughing or sneezing?*

No
Yes

Please explain (how often, for how long, after a certain activity, etc.)*

Is your pet currently taking any medications?*

No
Yes

Please list medications, supplements, vitamins, herbal products, flea and/or heartworm preventions, and the dosage/quantity you are giving for each.*

Does your pet have any known allergies?*

No
Yes

Please explain (what are they allergic to and what is the reaction?)*

Has your pet ever had any reactions to injections or vaccines?*

No
Yes

Please explain (which vaccines and what is the reaction?)*

Have you noticed any changes your pet’s activity level or their ability to move around?*

No
Yes

Please explain*

Is your pet showing signs of pain?*

No. Not that I can tell.
Yes

Please explain*

Have you noticed any changes in your pet’s personality (disorientation, vocalization, signs of aggression, etc) or sleep habits (sleeping more that normally, pacing or restlessness at night, etc)?*

No
Yes

Please explain*

Does your pet go to a groomer, boarding facility, dog park, dog/cat shows or day care?*

No
Yes

Please explain*

Does your pet travel with you?*

No
Yes

Please explain*

Is your pet currently on a wellness plan?*

Yes
No

Have you downloaded our app and are a member of our loyalty rewards program?*

Yes
No

Download to start earning: https://funkstownvet.com/download-our-app/

Would you like an estimate provided for services?*

Yes
No

If you or a member of your family have traveled out of the state within the last 14 days, or if you or a member of your family are experiencing any signs or symptoms of COVID or have been in contact with someone that has tested Positive for COVID within the last 48 hours then we ask that you contact us immediately to reschedule your appointment.*

I understand the statement above.

Upon arriving to your appointment, you MUST CALL to let us know that you are here. If you are unable to reach a person, please continue to CALL BACK until you are able to speak with a staff member. We appreciate your patience at this time. We are doing our best to be as efficient as possible, but our phones lines can sometimes all be in use.*

I understand the statement above.

Name

This field is for validation purposes and should be left unchanged.