Pre-Visit Questionnaire Pre-Visit QuestionnaireClient and Pet General InformationClient First NameClient Last NameClient EmailPhone NumberPet NamePet Species Canine FelinePer BirthdatePet Weight (in lbs.)Pet Gender Female intact Female spayed Male intact Male neuteredHas your pet been to other veterinary clinics in the past? Yes NoWhich clinic?If you are able, please have the previous clinic email your pet’s medical records to pets@homepetvet.wpenginepowered.comDo you have pet insurance? Yes NoWhich plan?Pet HistoryDo you have any specific concern(s) about your pet that you would like the doctor to address on his/her visit? Yes NoPlease describe your specific concern(s)Indoor/Outdoor? Mostly indoor Mostly outdoor Close to a 50/50 splitMultiple Pet Household (dogs or cats)? Yes NoHeartworm, Internal Parasite, Insect Preventative’s given regularly all year? Yes NoWhen are they given? I just forget some of the time I do not give in the winter months Other, please describe:What brands of Heartworm, Internal Parasite, Insect Preventative’s do you use?Do you know when your pet last received a vaccine? Yes NoWhat month and year did your pet receive a vaccine?: If you know what vaccines where given at that visit, please list them here:Has your pet ever had a reaction to a vaccine? Yes NoHave there been any changes in eating or drinking? Yes NoPlease describe the changesHave there been any changes in urination (amount, frequency or appearance)? Yes NoPlease describe the changesHave there been any changes in bowel movements (amount, frequency or appearance)? Yes NoPlease describe the changesAny loose stools/diarrhea? Yes NoHas there been any signs of stiffness, soreness or pain? Yes NoPlease describeHave you noticed any discharge or buildup of material around the eyes? Yes NoHave you noticed any coughing or sneezing? Yes NoPlease describeHave there been any changes in your pet’s energy levels? Yes NoPlease describeIs your pet on any current medications? Yes NoPlease describeDoes your pet currently have a veterinary diagnosed medical condition? Yes NoPlease describeHas your pet had a veterinary diagnosed medical condition in the past? Yes NoPlease describeNutrition AssessmentHow active is your pet? Very active Moderately active Not very activeHow would you describe your pet’s weight? Overweight Ideal weight UnderweightDoes your pet receive table scraps? No Yes, but not regularly Yes, regularlyDoes your pet receive any dietary supplements (i.e. vitamins, glucosamine, fatty acids)? Yes NoPlease list brands and amountsHow do you provide food to your pet daily? I always keep the food in the food bowl I only feed a measured amount each dayDoes your pet eat other pet’s food? Yes, rarely Yes, often No Please list all non-table scrap foods that your pet receives on a daily basis: (click the plus button to add additional lines) Food (Brand or type) Form (i.e. dry or wet) Amount Times/day or week Fed since (MM/YY) Fear, Anxiety and Stress Assessment As a Fear Free Certified Professional team, we want to make your pet’s veterinary experience as enjoyable and as stress free as possible. As such, it’s important for us to understand what your pet might find upsetting. The information will help us to adjust our care to better serve and comfort your pet. Please answer the following questions to the best of your ability so we can take into consideration both your & your pet’s preferences.How would you describe your pet’s past reactions to veterinary visits? Never seen a veterinarian Loves the experience Mild hesitation and anxiety, but acclimates quickly Moderate anxiety, but calms down some and behaves Moderate anxiety and never really relaxes (i.e., trembling, tail curled, won’t come out of carrier) Severe anxiety (i.e. hiding, growling, trembling, panting/drooling)Has your pet ever bitten anyone? Yes NoCheck any of the below that your pet has shown avoidance or dislike of in the past Being approached by a stranger Strangers entering a room they occupy Doorbell ringing Knocking on the door Veterinarians in white lab coats Being lifted Direct eye contact with strangers Loud voices Thunder or fireworks Having rectal temperature taken The use of instruments such as stethoscope or otoscope (to look in ears) Having their mouth opened Having their nails trimmedHow would you describe your pet around other animals and people?Does your pet have any sensitive areas that he/she does not like to be touched?Are there any veterinary procedures that your pet experienced in the past that he or she did not appreciate? How did they react?Are you interested in being contacted to see if mild oral sedatives are warranted for the Home PetVet visit? Any anxiety level of moderate or greater would benefit. These tablets would be mailed to you to be given to your pet approximately 90 minutes prior to the appointment. Yes NoThank you for taking the time to answer these questions! This will make our time together in the future much more productive.Submit Form
