Patient History Questionnaire for Wellness 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.

Is your pet eating and drinking normally?*

Yes, they are eating and drinking normally.
No.

Please explain*

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

Have you noticed any of the following?*

Other*

Please describe the frequency and provide details for all symptoms selected above*

Is your pet currently taking any mediations?*

No.
Yes.

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

Are you interested in updating your pet’s annual heartworm test if due?*

Yes. Please screen my dog for HW and tick-borne diseases.
No. I am not interested at this time.

For Feline patients that travel or spend time out of doors we recommend cats be screened for FELV (Feline Leukemia) and FIV annually. Are you interested in updating your pets annual FELV/FIV test?*

Yes. Please screen my cat for FELV and FIV.
No. My cat only goes outside for their annual wellness exam.
No. My cat does go outside, but I am not interested in screening them at this time.
No. My cat lives indoors and has already been tested.

Are you interested in updating your pet’s vaccines?*

No
Yes

Which vaccines are you interested in today?*

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?)*

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*

Do you have other pets at home?*

No
Yes

What other pets do you have?*

Please describe your pet's dental care regimen. (brushing (type of paste and frequency), food or water additive type and frequency, oral diet type and frequency, dental treats: brand, quantity, and frequency, other)*

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?*

No. understand the costs associated.
Yes. Please provide me with an estimate prior to rendering services.

Because of possible zoonotic risks, the CDC recommend that every pet be checked annually for internal parasites. Therefore, we ask that you please bring a fresh fecal sample with you to your pet’s visit. Samples will be submitted to a lab for analysis and the results will be available with 48 hours of your visit.*

I understand the statement above.

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.

Phone

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