Door County Veterinary Hospital

3915 Old HWY Rd.
Sturgeon Bay, WI 54235

(920)743-7777

www.doorcountyveterinaryhospital.com

History Questionnaire

 

Please answer the following questions, if the answer is Yes, please expand on the type, amount, frequency…

 

History Questionnaire Form

Pet Owner's Name (First and Last): (required)

Pet's Name: (required)

Date of Scheduled Appointment: (required)

Does your pet have a history of seizures? (required)

Is your pet indoor, outdoor or both? (required)

Is your pet currently on any medications? (required)

Are you giving your pet anything over the counter (vitamins/supplements/aspirin/etc.)? (required)

Do you use heartworm preventative? If so what kind and frequency? (required)

Do you use a flea preventative? If so what kind and frequency? (required)

Is your pet scratching or itching? If so where and how often? (required)

Does your pet have any allergies you are aware of (seasonal or food)? (required)

Does your pet cough? If so, when and how often? (required)

Does your pet sneeze? If so, is there any discharge and what is the color? (required)

Any increase in drinking or urination? (required)

Does your pet vomit? If so when and what is the consistency? (required)

Is your pet's stool abnormal? (required)

Any lumps or growths? Any change in size or consistency? Please be prepared to point them out. (required)

Any limping or soreness? If so, in what location? (required)

Does your pet hunt? (required)

Do you travel outside of the state with your pet? (required)

Do you bring your dog to boarding facilities? (required)

Do you have your pet groomed? (required)

Does your cat use the litterbox consistently? (required)

Do you have any other pets? If so, what are they and how many? (required)

What kind of food do you feed your pet? How much and how often? (required)

Does your pet get treats? What kind and how often? (required)

Does your pet receive table scraps or people food? (required)

What is your pet's most notable attribute?

What is your pet's nick name?

Any additional questions, concerns, or information you would like to let the Doctor know today?

Any additional services requested today?


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