New Patient Questionnaire

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Name*
First Last
Pet's Name*
Pet's Age
Phone*
Email*
Reason for Appointment
What do you currently feed your pet?
Have you noticed any changes in your pets appetite or thirst?*
- Yes
- No
If yes, what are the changes?
Have you noticed any abnormal vomiting or diarrhea?*
- Yes
- No
Has your pet lost or gained a significant amount of weight since your last visit?*
- Yes
- No
Has your pet had any problems urinating or defecating?*
- Yes
- No
Does your pet go camping and/or hunting?*
- Yes
- No
Does your pet go outside unsupervised or have exposure to wildlife?*
- Yes
- No
Does your pet sleep in bed with you or your children at night?*
- Yes
- No
Do you board your pet when you leave town?*
- Yes
- No
Does your pet swim or get bathed frequently?*
- Yes
- No
Does your pet get groomed or go to dog parks or other public places?*
- Yes
- No
Has your pet ever had blood work done before?*
- Yes
- No
If yes, when was the blood work last done?*
And why?*
Is your pet currently on monthly Heartworm prevention?*
- Yes
- No
If yes, what kind?
Is your pet currently on any monthly flea or tick preventative?*
- Yes
- No
If yes, what kind?
Does your pet have pre-existing medical conditions?*
- Yes
- No
If yes, what conditions?
Is your pet currently on any other medications?*
- Yes
- No
If yes, what kind?
Have you noticed any limping or other concerns with your pet's mobility?*
- Yes
- No
If yes, explain
Is your pet microchipped?*
- Yes
- No
Is your pet spayed/neutered?*
- Yes
- No
Does your pet receive any home dental care?*
- Yes
- No
If yes, what kind?
Do you have any children or grandchildren in the household?*
- Yes
- No
Did you bring in fecal sample today to check for intestinal parasites?*
- Yes
- No
Would you prefer a topical or oral pill for parasite prevention?
- Topical
- Oral
Do you have any specific concerns or questions for the doctor today?

Peoria Area Veterinary Group of Chillicothe

1310 W. Truitt Avenue
Chillicothe, Illinois, 61523
309-274-6509

Peoria Area Veterinary Group of Dunlap

4620 W. Cedar Hills Drive
Dunlap, Illinois, 61525
309-243-7784

Peoria Area Veterinary Group of Peoria

2815 W. Townline Road
Peoria, Illinois, 61615
309-691-0220

All Location Hours

Monday	8:00AM-5:00PM
Tuesday	8:00AM-5:00PM
Wednesday	8:00AM-5:00PM
Thursday	8:00AM-5:00PM
Friday	8:00AM-5:00PM
Saturday	8:00AM-12:00PM
Sunday	Closed