To help us provide the quickest and most appropriate care for your pet please fill out the questionnaire below. This will help us pinpoint how to best treat your pet when they are seen. Our staff may ask additional questions at that time to further explore any issues your pet is experiencing. Owner’s Name* Patient’s Name* Have you noticed any lumps, bumps, growths, non-healing sores, or swellings? YES NO If so, describe where: Have you noticed any coughing, sneezing, or difficulty breathing? YES NO Has your pet experienced any vomiting or diarrhea? YES NO If so, when was the last instance of vomiting or diarrhea? Does you pet have any ear problems? Check all that apply: Head Shaking Scratching Sensitivity Odor Discharge None Have you noticed any excessive itching or scratching? YES NO Is your pet having urine or stool accidents in the house? YES NO Does you pet visit groomers, parks, boarding facilities, stores, etc. where it could come into contact with other animals? YES NO What diet do you feed your pet? (Please list brand, amount, wet/dry) Has your pet had a normal appetite? YES NO What treats or table food (people food) does your pet receive? What flea/tick and/or heartworm prevention is your pet on? When was their last dose given? Do you have any health or behavioral concerns regarding your pet that you want to discuss with the doctor? YES NO If so please describe: CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.