Client Name*

First

Last

Patient Name

What diet are you feeding (including treats or table foods?)

How much are you feeding?

How many times daily do you feed per pet (s)?

Do you have any other pets at home?

Yes
No

How often does your pet:

Visit the groomer?

Use a boarding kennel?

Go to day care?

What percentage of the time does your pet spend outdoors?

Have you noticed any:

itching/scratching
licking of the feet
skin growths

Have you noticed any:

scratching at the ears
smell from the ears

Is there any odor to the breath?

Y
N

Have you noticed any:

sneezing
coughing
discharge from the eyes or nose?

Have you noticed any limping?

Y
N

Does he/she have any trouble:

getting up
climbing stairs
jumping/running

Has there been any recent:

vomiting
diarrhea
scooting

If yes, how long ago and how often

Has there been any change in frequency or amount of urination?

Y
N

Has there been an increase in water consumption?

Y
N

Has there been a change in appetite?

Y
N

If yes,

Increased
Decreased

Has there been a change in sleep patterns?

Y
N

Has your pet had any accidents in the house?

Y
N

When was the last time you gave your pet heartworm/flea preventatives (please list the name of each and when given):

Do you need a refill on flea and tick or heartworm prevention?

Which brand of preventions are used?

Does your pet have any contact with wooded area?

Y
N

Are there any deer or wild animals that visit your yard?

Y
N

Do you take your pet camping or to lakes?

Y
N

Have you seen any stray dogs or cats in the neighborhood?

Y
N

Is there any long grass or tall weeds next to your yard in a common area or neighbor’s yard?

Y
N

How is mobility?

Limping
Skipping
Difficulty jumping
Difficulty with stairs

Is there anything else that the doctor should know about?

*It is always best if you can collect and bring a 12-hour fresh fecal sample with you to your pet’s appointment.

Patient Wellness Form

Patient Wellness Form

How often does your pet: